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S40quin County Public Health SerG* <br />Environmental Health Division <br />Medical Waste Management Program <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 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 Ile one of the following: <br />1- Medical Waste Management Plan if the genertor <br />or parent organization is a large quantity generator or a small <br />quantity generator required to register pursuant to Chapter 4. <br />2- Infonnation 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 CM Renewal <br />Medical Office/Business Name:, Stockton Fire Department <br />Medical Office/Business Address: -44-9-%.- -8-011 - L a 9 t r cc t425 N FI N-"MA'n - <br />City: Stockton State. CA Zip Code: 9520,32 - <br />Contact Person: Battalion Chief Carl Eck Phone #(202) 937-801 <br />Storage Facility Name: ' <br />)jDr,=t,) RW <br />Storage Facility Address: I IQ L&) =ZZ. <br />City: State., CA- Zip Code: -q � k� <br />Permitted Treatment Facility Name: Ila <br />Permitted Treatment Facility Address. 41261- L�, ,�(6a(2L Ave <br />State: ca= Zip Code: <br />City: Mae --k <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />1- Name: Companies 1,2,3,4,5,6,7,9,10,11,12,14 Title: Drivers (A.B & C Shifts) <br />2- Name: Title: <br />3- Name:— Title: <br />A copy of this exemption and a tracking document shalloy b <br />l eels possession at all times while transporting medical waste. In <br />addition, all copies of medical was_te recor"shad )''Vpt on file at generator's or health care professional's facility. <br />Applicant Signature: 4 c -- <br />Title :_ Batton Chief Date: 2 / 22 / 99 <br />Do Not Write Below This Line <br />R.E.H.S. Application Approval: —11f 1, Date:' -r / 7-1hxpiration Date: <br />(circle) Acct <br />10 '79F9 -7 - <br />Date Paid i' -� / jQ5 q4 Cash o�� # 4 <br />E114302 10-03-96 <br />