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SiMoaquin County Public Health Sero <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 Act', the following <br />conditions must be met <br />The generator or health care professional generates less than 20 pounds of medical waste per weals, 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 $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 -A Renewal <br />Medical Office/Business Name: 56C—X760✓ �! 4C d7,15?,eeW fe—&J'-' <br />Medical Office/Business Address: C -Z5'" 'Ez NV- <br />City: L�� State: Com' Zip Code._ = Z o 2 <br />Contact Person .� <br />r -a-r' 4 Phone <br />Storage Facility Nae: !.4'f 2" <br />m�" ' <br />Storage Facility Address: <br />City: State: (2& Zip Code: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: _ 4i "r °'`3'%`f <br />State: (tt•& c Zip Code:! <br />City:_ <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />1- Name: /i?� �/►/ �d..I Title: <br />2- Name:—�i2�a,r,S Title: <br />3- Name: .a Title: <br />A copy of this exemption and a tracking document shalt be in employee's possession at all times white transporting medical waste• In <br />addition, all copies of medical waste records shall be kept on file at generators or health care professional's facir§ty. <br />Applicant Signature <br />✓� i✓ Date: / Z ` / W17 <br />Title: <br />Do Not Write Below This Line <br />Date: oZ / / piration Date -.112: /3/ l D� <br />lZ.E.H.S. Application Approval: o <br />EH4502 10.03-96 Date Paid 2 / o_ / OZ Cash or Chec< T 4829 (circle? Acct <br />