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San Joaquin County Public Health Servi s <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 Aet% the following <br /> conditions must be met <br /> The generator or health care professional generates less than 20 pounds or 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 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 S67 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 X Renewal <br /> Medical Office/Business Name: �J l <br /> Medical Offs e/Business Address [ State: Zip Cade: <br /> City. n Phone T ( r- <br /> Contact Person: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> State: ��ZZ�ipCode: �� <br /> City: <br /> Permitted Treatment Factiirf Name: J �tate:Permitted ea ent Face'ty Address: v _1Zp Code: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> v title: <br /> 1- Name: Title: _ ? <br /> 2- Name: Title:__.�",�,i' a - — <br /> 3- Name: <br /> A copy of this exemption and a ckin doc shall be in employee's possession at all times while transporting medical waste. in <br /> addition, all copies of medical re rads be kep n file at generator's or health care professional's facility. <br /> C <br /> Applicant Signature: Date: — <br /> Title: <br /> Do Not Write Below This Line ? ,Z <br /> Sy R.E.H.S. Application Approval:-= 1 Date:� piration Date: �Z <br /> EH4502 10.03-96 Date Paid /off._-___�/__--- <br /> Cacho Chec< ' .�7.?7 (circle) Acct /i <br />