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• San Joaquin County Public Healoervices <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 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 $67 FEE TO: PAYMENT <br />San Joaquin County Public Health Services RFCElven <br />Environmental Health DivisionC(DP <br />JAN 161998 <br />Medical Waste Management Program <br />304 E Weber Ave SAN JOAOUIN COUNTY <br />PUSUC Stockton, CA 95202 <br />ENVIRONMENTAL HEALTALTH HOIVISION <br />❑ New a Renewal <br />Medical Office/Business Name:_ <br />Medical Office/Business Address: <br />City: <br />Contact Person: At,)vj2_z�7,o fk . <br />Medical Waste Hauler Information <br />State: Zip Code: <br />dzZ Phone <br />Storage Facility Name: 3 <br />Storage Facility Address: _LLCM LxD <br />City: f:�>"nr e __ State: Zip Code: <br />Permitted Treatment Facility Name:- t�.)r l K601L- LQh2 <5 <br />Permitted Treatment Facility Address: 14 k -2, <br />�a ; �� <br />City: r�IC.P-(�.►,�,�� State: C,�, Zip Code: <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />1- Name:, ` s �'�C-gy p Title: <br />2- Name: Title: <br />3- Name: �--�._ Title: <br />A copy of this exemption and a Ing docume s Il -ems pmsession at all times while transporting medical waste. In <br />addition, all copies of I, to cords s all a ept tegeneratoes or health care professional's facility. <br />Applicant Signature: <br />Title: GIBS c ``fit \L\i�(2, Date: <br />Do Not Write Below This Line <br />R.E.H.S. Application Approval4ft�V <br />Date: ! / Expiration Date: / <br />I/ <br />Haso2 10-03-96 Date / ! / Cash or Check #. qO g300 (circle) Acct <br />