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On Joaquin County Public Health ices <br /> Environmental Health Division <br /> Medical Waste Management Prcgram. <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality 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 ticking document-{pursuant to Chapter 6, and the <br /> generator or parent organization has on the one of the following: <br /> 1- Medicai 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 S6T 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 Renewal <br /> Medical Office/Business Name: <br /> Medical ofnce/Business Address: <br /> City: State: � Zp Code: o? y <br /> Contact Person: l i'l G Phone ,�Da- <br /> Storage Facility Name: U <br /> Storage Facility Address: <br /> City: �d'�' - State: Zp Code: �7 <br /> Permitted Treatment Facility Name: Pic <br /> Permitted Treament F�afjility Address: <br /> City: ��Crt���� State: Zp Code: <br /> T <br /> L ist all employee names and tides 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 tracidn d urnent shall b oyee's possession at all times while transporting medical waste. In <br /> addition. all copies of medical c ept file at generator's or health teas professianaCs facility. <br /> Applicant Signature: <br /> ::n <br /> t.17 Date: <br /> Do Not Write Below This Line <br /> R-E.H.S. Application Approval: <br /> Date: Z// IO Expiration Dater/3/ 102' <br /> EH4502 W-03-96 Date Paid 12/ b I Cash ec< Zn1�5 (circle) Acct <br />