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s^ <br /> San Joaquin County Public Health Servi <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 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 file one of the following: <br /> 1- Medical Waste Management Plan <br /> f n if the <br /> repursua generator to Chapter 4 ganization is a large quantity generator or a small <br /> quantity generator req <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 $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 /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical of iice/Business Address: 2 Z <br /> State: Cca Zp Code: Q 5 21, <br /> City: Phone <br /> : Q -�1 <br /> Contact Person: <br /> Storage Facility Name: <br /> Storage Facility Address: State: �'.Z!P Code: Q`�--)t-n-- <br /> Ci Ci <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: State: Zip Code: -14(oQ I <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Title: 2N SupeX�i Sod <br /> �- Name: Z�` � Title: LUN <br /> 2- Name: Title: <br /> 3_ Name: <br /> and a tracking document shall be in em possession at all times while transporting medical waste. In <br /> A copy of this exemptionessiorsal's facility. <br /> addition, all copies of medical waste records shall be kept an file at generator's or health care prof <br /> 1ln � �\1�'���il"L4�Q <br /> Applicant Signature: Date. i?= /o� /OO <br /> Title: <br /> Do Not Write Below This line <br /> roval: Date: / Z� Expiration Date: l Z l 3r 1 <br /> R.E.H.S. Application App , J 0 Eo� (circle) Acct 2Gr✓ <br /> EHa502 10-03A6 <br /> Date Paid eZ / - /U Cash o Check <br />