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SaWbaquin County Public Health Sery ® 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 U Renewal Medical Office/Business Name: Lawrence ivermore Nat-innal T.ahnratarg - sir. ',nn Medical Office/Business Address: Corral Hollow Road City: Tracy State: CA Zip Code:_9 537 h Contact Person: Vicki Salvo Phone t (92 5) 423-5432 Storage Facility Name: Browning Ferris Industries Storage Facility Address: 90 North 1100 West City: North Salt Lake City State: Utah Zip Code: 84054 ( See attac a or a ition l sto a e fnri1it),) wn�� r lei i Permitted Treatment Facility Name: Browning Ferris Industries Permitted Treatment Facility Address: 90 North 1100 West City: North Salt Lake City I State: Utah Zip Code: 84054 List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: Linda Garcia Title: Registered Nurse 2- Name: Rob Tageson Title: jigzardou,5 Waste Managgment Tach 3- Name: Joe Stonich Title: Hazardous aste Management Tach A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition. all copies of medical waste records shad be kept on file a=toe Itit care professional's facility. Applicant Signature: C. Susi Jackson Title: Division Leader — Operations & Regulatory Affairs ision Date: D Do Not Write Below This Line R.E.H.S. Application Approval: Date: / / Expiration Date: EH4502 10-03-96 Date Paid / / Cash or Check T (circle) Acct