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40an Joaqu ounty Public Health Ices • <br />EnviWmental Health Divisio� <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: <br />San Joaquin County Public Health Services <br />Environmental Health Division 00� <br />Medical Waste Management Program <br />P.O. Box 388 <br />Stockton, CA 95201-0388 <br />Medical Waste Hauler Information <br />❑ New 2 Renewal <br />Medical Office/Business Name: Stockton Fire Department <br />Medical Office/Business Address: '425 N. El Dorado Street <br />State: Zip Code: <br />City: <br />Contact Person: Captain Paul Willette Phone #: 937-8019 <br />Storage Facility Name: Stockton Fire Department, Station #2 <br />Storage Facility Address: 110 W. Sonora Street <br />State: Zip Code: <br />City: <br />Permitted Treatment Facility Name: BFI Medical Waste Systems NWTS Permit /199-00043-P <br />Permitted Treatment Facility Address: 4135 W. Swift Avenue <br />City: Sacramento 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- <br />Name: <br />See attachment (Current engineers, <br />Title: <br />2- <br />Name: <br />relief pool <br />and <br />Title: <br />3- <br />Name: <br />Division of <br />Training <br />Title: <br />A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br />addition, all copies o ste records shalWkon leat generator's or health care professional's facility. <br />Applicant Signature: <br />Title: Ik�+.� �lTo�►.1i Date: 12 / i7 <br />Do Not Write Below This Line <br />R. E.H.S. Application Approval: / te: i I � Expiration Date: <br />EH4502 10-03-96 Date Paid / / Us Cash or Check (circle) Acct <br />