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M <br />San quip County Public Health Servic pf& <br />�-lA` <br />q9triviro Health DivisionzI"�I <br />Medical Waste Management Program JAN 18 2,1 301 <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION SAN JOAGUINCOUNrY <br />PUBUC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the following <br />conditions must be met: r <br />T <br />e generator or health dare 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 NewXRenewal <br />Medical Office/Business Name:. ktoo Fl D�_'�rj-✓4 M ems+ 1f" <br />Medical Office/Business Address: Z S" 1\i , ! -L-)e--,v-;,4r4,) & <br />CiIy: +Uc,kln State: CA Zp Code: 1? S 2 o z <br />Contact Person:- n F' u l W:1 e-, Phone;: 1 3 7 -Hol `7 <br />Storage Facility Name: bhickk�vo Ft' •'_- D� �n cam-.^�! -n <br />Storage Facility Address: d lO W <br />City: 5 --o c O -o o State: CA Zip Code: `1 5' ,- 0 3 <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: 4-13-s- VT 33 w i <br />City: S,3c'.V. rn ,4v State: CA Zip Code: 17 <br />List ail employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />1- Name: 1,Z13,4,541-,17411, 10,// 12. /4 Title: 'PiriVew-s 6A,Lj+r �F4.5 <br />2- Name: Title: <br />3- Name: rile: <br />A copy of this exemption and a ckian <br />ng document shall be in employee's possession at all times while trsporting medical waste. In <br />addition, all copies of medical re rds shad be kept on file a/t' generator's or health care professional's facility. <br />Applicant Signature: 1' <br />Title: �Vc �ro�t /✓li r �� 52�/ �c°s kiV Date: 1 Z/ <br />Do Not Write Below This Line <br />R.E.H.S. Application Approval ate: /,2V piration Dater/ 5—/-/jQo <br />EH4502 10-03-96 Date Paid d/ / / / Cash or Che 5/06' 5S (circle) Acct <br />