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Saaquin County Public Health Ser* <br />Environmental Health Division <br />Medical Waste Management Program <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />To quality for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the following <br />conditions must be met: <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 an 5ie one of the fallowing: <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 € ELOW AND MAIL WITH $67 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 />n New 7� Renewal <br />Medical Office/Business Name:— <br />Medical Office/Business Address: <br />City: 5- <br />Contact Person: <br />Medical Waste Hauler Information <br />Coatpt � ee �-, <br />S <br />Code: S 2-4d`Z- <br />me � i 0 <br />Storage Facility Name: YCLCE, <br />Storage Facility Address: ` <br />City: -`a c �i 't State: CA Zip Code:P-. <br />_25Z <br />Permitted Treatment Facility Name: aS e v'r c. e <br />Permitted Treatment Facility Address /3� Lt1a-S`c��a "�` Vle <br />C!ty: Fy-e 5K e1 State: Cp+ Zp Code: 931722 <br />List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. <br />1- Name: ,:a&Ckrr i Tine: <br />2- Name: Title: <br />3- Name: Title: <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 reco tm11 be kept on file at generator's or health care professicfWs facility. <br />Applicant Signature: o <br />Title: ~F �er�► M'-,� Date: <br />Do Not Write Below This Line <br />L <br />Q.E.H.S. Application Approval: Date: I -LV Z< Z -Expiration Date: /3 / 3 (/ Q� <br />El -I4502 10-03-96 Date Paid z-4 / O % Cash or Check T 5 �S`2 (circle) Acct <br />