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SleJoaquin County Public Health Seros 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 W Medical Waste Management Program 304 E Weber Ave !� Stockton, CA 95202 Medical Waste Hauler Information ❑ New ZI Renewal Medical Office/Business Name: Lawrence Livermore Nati nasal T ahnrnt orW — Si tP 'Inn Medical Office/Business Address: Corral Hollow Road City:_ Tracy State: CA T!p Code: 95376 Contact Person: Vicki Salvo Phone t125) 423-5432 Storage Facility Name: Browning Ferris Industries - Storage Facility Address: 90 North 1100 West City: North Salt Lake Cit State: Utah Zip Code. 84054 ( see attache or a i conal storage farilitvl 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 Taizeson - Title: Hazardous Waste Management Tech 3- Name: Joe Stonich Tide: Hazardous Waste Management 'tech 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 shall be kept on file at tors or h aith care professional's facility. Applicant Signature: C. Susi Jackson Title: Division Leader - Operations & Regulatory Affairs ' ision Date: c Do Not Write Below This Line R.E.H.S. Application Approval /!/Ils te: I //l 4','1-'! Expiration Date: ly EH4502 10-03-96 Date Paid ' / �� /U Cash or eck : Z2,rc,,1�'3 (circle) Acct-L4-1