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San Joaquin County Public Health St_qqles <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 Act% the following <br /> conditions must be met: <br /> pounds of <br /> l waste per week. , <br /> the generator or health care pro at any one time, maingenerates less tai s an a trading document pursuant to Cti pt�e 6,orts andless <br /> the <br /> :han 20 pounds of medical wasteY <br /> generator or parent organization has on file one of the following: <br /> Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small pursuant to Chapter 4. <br /> 1- <br /> quantity generator required to register <br /> 2- <br /> 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 $GT FEF TO: <br /> San Joaquin County Public Health Services RECEIVED <br /> Environmental Health Division <br /> Medical Waste Management Program DEC 14 2001 <br /> 304 E Weber Ave Sav Jo;:I !?l ca "y <br /> Stockton, CA 95202 F s <br /> Medical Waste Hauler Information <br /> n New enewal � <br /> Medical office/Business Name:. A t' <br /> Medical office/Business Address: State: Zp Code. l� <br /> City:__ C �C[� O Phone 5 91 0_ <br /> Contact Person: - <br /> t,(M�C. <br /> Storage Facility Name: ` w <br /> Storage Facility Address: State: Tip <br /> City: St4U�-Yu <br /> Permitted Treatment Facility Name: �1t1 <br /> Permitted Treatment Faciiiy Address: State: C�3 Zp Code: <br /> City: NI <br /> List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. <br /> �/ C L Title: wd <br /> I- Name. DG�`)�Jll Title: — <br /> 2- Name: vl Title: <br /> 3- Name. S'4 <br /> A �� �COI1T(n� possession at all times while transporting medical waste. In <br /> ' document shall be in employee'sessionars facility. <br /> A copy of this exemption and a tracking <br /> addition. all copies of medical waste cords shall be kept on file at generators or health care <br /> APP licant Signature: Date: <br /> Title: '' <br /> Do Not Write Below This Line <br /> royal: Date: �_�u�P <br /> iration Date• g ; 1 2. <br /> Q.E.H.S. Application App L6. <br /> :;-t�ti02 10-03-96 <br /> Gate Paid /�2 / / /D/ Cash or hec lI_ �S(circle) Acct <br />