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FkUM 0 P_2 <br /> San Joaquin County Public Health Services <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 Acr,, 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 on rite one of the g: <br /> 1- Med/cal Waste Uanagement 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- lnfmnafron 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 $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 /> Medical Waste Hauler Information <br /> 0 New 0 Renewal <br /> Medical usiness Name: Sin U( <br /> Medical Office/Business Address: -e <br /> state:___�'_0.._ . Zip Code:,,, <br /> Contact Person: ,`KlCi �`/limns Phone#: LI G�0 <br /> Storage Facility Name: <br /> Storage Facility Address' a tiJ <br /> City: State: Zip Gcsde: T <br /> Permitted Treatment Fadilty Name: <br /> Permitted Treatment Facility Address: 9 i <br /> Cky:--- -i d -- t , State: d~= 4p Code: !a i j:�-3 <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> I- Nairne: r i`sr Tilde: <br /> 2- Name: ; <br /> 3- Name.• -Rge• <br /> A copy of#ft exemption and a tracking document shall be in employes's possd=lon at all tines while trans <br /> porting medical waste. in <br /> sddrtron,da copies of medical waste rocorft sha0 to kept on file at generator's or hearth care ional's facility. <br /> Applicant Signature: <br /> Tate: L-P-�..�. 9.4 ,•�,� ,2i —Date: Ca ! �t 1_„(?`� <br /> Do Not Write Below This Line <br /> R.E.H.S.Application Approval: Date: !Z{/ Expiration Date: ! ! <br /> EM4502 10-03-96 Date Paid 44.41 &h or Check#__,EI✓� (circle) Acct�( �— <br />