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SAN AQUIN COUNTY PUBLIC HEALTH CES VIRONMENTA,L HEALTH DIVEST Medical Waste M- gr Program APPLICATION FOR A LIMITED QUANTITY HAULING EMNUyIZON To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", you are required to meet the following conditions: I- Your medical office/business generates less than-20 pounds of regulated medical waste per week. , 2- Your medical office/business transports less than 20 pounds of regulated medical waste at any one time. 3- Your medical office/business maintains records of any regulated medical waste transported offsite for treatment and disposal, including the quantity of the waste transported, the type of the waste transported, the date the waste was transported, the name of authorized person that transported the waste and the destination of the waste. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH$67 APPLICATION FEE TO: r- �K�o�o3 7 '`�: , San Joaquin County Public Health Services �5 s7 Environmental Health Division P.O. Box-290'9- 3`3 S Stockton, CA 95201-C3<,3-S' _ Medical Waste Hauler Information c•.: Medical Office/Business Name: 5rk P 5d Prc-� LA-k To <7-nu mT y ?c,—b k c-Nes► H a ',>ar J i c.e.S Medical Office/Business Address:i bo I City: ,(--t-n State: C-C; Zip-Code: o I Contact Person: Phone : L--&,R Permitted Treatment Facii'dy Name: =ht'e�q rA rnvtrorn-n4l f7 � sit #: ;2- (P9,.1- Permitted Treatment Facility Address: `t�� t-4gin :5+ City: State: C Zip Code: ei c.o 1 rflo Zle4�t- St / 2- Please Please list employee names and titles authorized to transport the medical waste. 1- Name: r'-�- Cvl.o K',cii e Tide: ti 2- Name: 4 fe e-r Title:— ID, t,) - 3- Name: J'i tai 11 i c-ms Title: Pl ct If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian or home health care nurse transporting medical waste back to own facility, please complete the following: Storage Facility Name: Scx-n Sfla,.:=k (�o"r\tv PLb L tc. 4,tai4i Permit #: ,y Rg Storage Facility Address: x Leo 1 i%• H-a-,- I -i-o r, City: �4o g- 4=u n State: Cipr Zip Code: '7 5 o-, A copy of this exemption and a tracking document containing the information above shall be in employees possession at all times while transporting medical waste. In addition, all copies of medical waste records shall be kept on file at your facility. Applicant Signature: 42:2 P,l� Title- RE.H.S. Application Approval: 74-ri, Date: EH 45 02 12-2-91