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S uin County Public Health SerA �� ���� �j <br />. a oaq <br />Environmental Health Division <br />Medical Waste Management Program <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the foilowing <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 on file one of the following: <br />1- Medical Waste Management flan 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 />C! NewARenewal <br />Medical Office/Business Name: <br />Medical Of lceiBusiness Address: <br />City: <br />Contact Person: <br />Medical Waste Hauler information <br />IfJ117 <br />o Code: <br />hone <br />Storage Facility Name: r � <br />Storage Facility Address: �S Al. .�tM �V'C2 2v� <br />s State: 111;4-Ztp Code: 95 <br />City: <br />111;4- <br />Permitted Treatment Facility Name: .Sfer'C P, c- Je <br />Permitted Treatment Facility Address: 5�/ 3 Gt/� SwiSf /4 Jt e - <br />City: <br />Fre sn o State: C�- Zlp Cade. (797,-2- <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />se.e �� C�jrfij Title: <br />1- 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 shad be kept on file at generator's or health care professional's facility. <br />Applicant Si <br />Title: <br />Do Not Write Below This Line <br />Date: / 110 /D cpiration Date: Z3ii 0 <br />R.E.H.S. Application Approval: ---T Z� <br />EH4502 10-03-96 <br />Date Paid 2 J I o/y Z o Chet �_ l'� (circle) Acct <br />