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San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information 0 New CR Renewal Medical OfftcelBusiness Name: Lawrence L' - Sit- 3ou- Medical office/Business Address: Corral Hollow- State: ra Zip Code: 95376 City: Trac a Vicki Salvo Phone T:g,25.[!�2'i-54'19 Contact Person: Storage Facility Name: Brownina Ferris Industries (Ster- Storage Facility Address: 90 North 1100 West North Salt Lake Cit State: Utah Zip Code: 84054 City' ac men or additional storage Permitted Treatment Facility Name: Browning Ferris Industries C9rPr;cv 1 Q� Permitted Treatment Facility Address: 90 North 1100 We,st State: ttah Zia Code: 84054 - City: North Salt Lake Cit —1--- List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. I- Name: Garcia Title: Rggi Ga^ �a N„rca Name: 2- Name: Rob Tageson Title: a Momt Tar}+ 3_ Name: Joe Stonich Title: Hazardous Waste MgMt- Tec A copy of this exemption and a tracking document shall be in employee's possession at ail times while transporting medical waste. in addition, all copies of medical waste records shall be kept on file at gens or he th care professional's facility. ,applicant Signature: C. Susi Jackson Date' Title- Division Leader/0 erations & Re ula Do Not Write Below This !eine . R.E.H.S. Application Approval: ®Date: t /(0 �q Expiration Date: ZLj5 EH4502 10-03-96 Date Paid Z / ZCash or Check a (circle) AcctA�