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V <br /> San oaquin County Public Health Servl <br /> Environmental Health Division <br /> Medical Waste Management Program MCLUV D <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI C 19 2000 <br /> To qualify fora "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Manag4ER' <br /> MIT wing <br /> conditions must be met: (SERVICES <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the <br /> generator or parent organization has on file one of the following: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> New A Renewal <br /> Medical Office/Business Name: T)'e_ 14-0., 6,l <br /> m� K__ <br /> Medical Office/Business Address: Al, c St. <br /> State: _ Zp Code: 952t>a <br /> City: <br /> � u.^'���*n't Phone <br /> Contact Person: �a <br /> AA <br /> Storage Facility Name: <br /> Storage Facility Address: �"��P-�� s <br /> State: Zip Code: <br /> CityZ- <br /> Peritted Treatment Facility Name: S lel-i CV C <br /> 11 e <br /> Permitted Treatment Facility Address state: C A Zip Cade. 9 ?22- <br /> City: <br /> the medical waste. If not enough space, attach information. <br /> List all employee names and titles authorized to transport <br /> C�t-� ',� Title: <br /> 1- <br /> Name: Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in <br /> addition. all copies of medical waste records s be kept on file at generator's or health care professional's facility- <br /> Applicant �(,cS� <br /> Applicant Signature: <br /> Title: 1!`c� tc`� 9Vlt OA le_ LQ''f�.t Date: / <br /> Do Not Write Below This Line <br /> Q.E.H.S. Application Approval: Date: 7/2 �Expiratian Dater 31 / <br /> EH4502 10-03-96 Date Paid 1 z / IQ /� / Cash or Check T �f3 (circle) Acct <br />