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San Joaquin County Public Health Services <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 Ac:', 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 fallowing: <br /> 1_ Medica! Waste Management Pian ifthe genera t to Chapter 4 organization is a large quantity generator or a small <br /> quantity generator required to registp <br /> 2- <br /> 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 FE 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 /> p New IRXRenewal <br /> Medical office/Business Name: Lawrence Liverm National Labarator- - <br /> l office/Business Address: Corral Hollow Road <br /> Medica <br /> State: CA Zip Code: 95376 <br /> City: Tracy Phone T:(925) 423-5432 <br /> Contact Person: Vicki Salvo <br /> Storage Facility Name: Browning. Ferris Industries Steric cle <br /> Storage Facility Address: 90 North 1100 West State: Utah Zip Code: 84054 <br /> City; North Salt Lake Cit <br /> gee attac tor a itona stora e aci it <br /> Permitted Treatment Facility Name: Brownin Ferris Industries Steric cle <br /> permitted Treatment Facility Address: 90 North 1100 West State: Utah Zp Cade: 84054 <br /> City; North Salt Lake Cit <br /> ►ist all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Title: Re>?istered Nurse <br /> 1- Name: Linda Garcia Title F 'nus t7aste Management Tech <br /> 2- Name: Rob Ta eson TitlerPment Tech <br /> 3_ Name: Joe Stonich <br /> shatimes while <br /> A copy of this exemption and a tracking document <br /> seen be k!<ept on file al be in l gene to se or health ssion at care professional's jtransporting <br /> m���waste.// In <br /> addition. all copies of medical waste re ,(!{ <br /> Applicant Signature: C. Susi Jackson C rah <br /> G,ra.d.C'. (j C.S art �ac( t <br /> Title.• Division Leader — 0 erations & Re ulator Affairs Division Date: t a: / �6 / Ov <br /> Do Not Write Below This Line <br /> Application Approval: Date: /I / Expiration Date:12/3 <br /> Q_E.H.S. App (circle) Acct <br /> EH4502 10-03-96 <br /> Date Paid ! ! Cash or Check T <br />