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San quin County Public Health Servi <br /> t , 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 Act'°, the following <br /> conditions must be met <br /> T he 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 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 /> 0 New (Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City: State: Zip Code: <br /> Contact Person: 6 _ /711,O L2 Phone 4 , — <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City: 1) State: CH Zip Code. <br /> Permitted Treatment Facility Name: <br /> Permittedeatrpent Facility Address: / <br /> City: 212 State: CA Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: bl- Title: <br /> 2- Name: rtle: �i� Al L <br /> 3- Name: + jo C rtle: <br /> A copy of this exemptio a d a trac g cc nt shall be n employee's p session at all times while transporting medical waste. In <br /> addition. all copies of m i I co s U be kept n file at tors or health care ptofessionars facility. <br /> Applicant Signature: <br /> Title: Dater <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: IM Date: <br /> EH4502 10-03-46 Date Paid-11i a / Cash or Check T .2� (circle) Acct <br />