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S oaquin County Public Health Se s PAyM <br /> Environmental Health Division RCC EiV�\/E <br /> � <br /> Medical Waste Management Program DEC ` <br /> 6 2002 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOKNJOAQUINQQUNry <br /> ENVfRONMFN HEALTH SERVICES <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac.", &L� lfdwli v <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per weak, tiwsparts 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 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 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 /> Q New 4 Renewal <br /> Medical Office/Business Name: m ` <br /> Medica Office/,Business Address: <br /> City: State: Zap Code: <br /> Contact Person: Phone : <br /> Storage Facility Name: <br /> Storage Facility Address: , <br /> City: ,-�(�i J State: ' Zip Code: <br /> Permitted Treatment Facility Name: <br /> Permit i Tr ment_�acifity Address: <br /> City: L �" Zip Cade: <br /> _-- <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Title' <br /> 2- Name: Title: <br /> 3- Name: Title: <br /> A copy of this exemption and a'tra Ong document shall be in employee's possession at an times while transporting medical waste. In <br /> addition, all copies of in rec shall be on file at generator's or health care professionars facility. <br /> Applicant Signature: �- <br /> Title: <br /> Date: <br /> Do Not Write 3 low This Line <br /> R.E.H.S. Application Approval: Date: / �?-Ezpiraiion Date: ..__ <br /> EH4502 10-03-96 Date Paid Cash rCheck (circle) Acct_____ <br />