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1907/1 18/2000 09:39 209468$3 FIFTH FLOOR 10 PAGE 02 <br /> San Joaquin County Public Health Service <br /> Environmental Health Division <br /> Medical Waste ane Ment Program <br /> APPLICATION FOR A LIMITED QUAN-nTY HAULING r:XEMPTICN <br /> i a 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 proftssional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, main ins a traddng document pursuant to Chapter 5, and the <br /> generator or parent organization has on file one of the following.* <br /> I- Medical Waste Management 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- Information Document If the generator or parent organ' at'on is a small quantity generator not- Uired to <br /> register pursuant to Chapter 4. <br /> PLEASE COMFLETE THF- INFORMAI ION BELOW AND MAIL W17111 $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> CD <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> Cl New G2(Renewal <br /> Medical office/Business Name:. �, L",a LA <br /> Medical office/Business Address: "Vf- <br /> City- state-- <br /> Cade: <br /> Contact Person: E:ft D <br /> Storage Facility Name: <br /> Storage Facility Add -7-7L4�ZLJ.SL� <br /> City: %kAnjn - <br /> --4p Cade: <br /> Permitted Treatment Facility Narnw.—L, <br /> Permitted Treatment Facility Address: <br /> City, S,1:Qc k L --ZIP Code:. <br /> List all employee names and tides authorized to transport the medical wast-a- If not enough space, attach 1nfbMVt!0n- <br /> Name- F/oi--a 10 ne's ntle: <br /> Name: -ritle: <br /> 3- Name ROW— Title, L M iV <br /> A copy of this exeraption and a tracking documeft strait be in @Wk7Y@W3 PO$66miGn at all tJMeB while omnsportlng medical wa5ft. Inr <br /> addltlor% all capies of medical Waste mv=ds_sbaA be kept an file a gonerato or twalth rare prolessionars facility. <br /> 77� <br /> Applicant Signature. <br /> Title: Date <br /> 00 Not Write Below This Line <br /> R.E.H.S. Application Approval. Date: I I Expiration Daft_--/——1 <br /> EM4102 10-03-96 Date Paid I J or Check (circle) Acr-t--. <br />