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Sar&aquin County Public Health Serv" <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality 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 Fi=E: 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 /> C] New %,Renewal <br /> Medical office/Business Name:. 1Z ~mac c-L JL c> ,t,C .D. a Q E. <br /> Medical Office/Business Address:- <br /> State: C-4- Zp Code: - <br /> City: - -- <br /> Contact Person: (� - — -_ A( &771=- _b_1__ Phone��� SO-28 <br /> Storage Facility Name: =A fL A P C <br /> Storage Facility Address: C- g ' <br /> City: S "T_e G. k State: Zip Code: <br /> Permitted Treatment Facility Name: S-7r= <br /> Permitted Treatment Facility Address: ® ° State: Zp Cade: ,�''o� -�45 <br /> City: P EF 12 L L t@ <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: <br /> 2- Name: L t Title: <br /> 3- Name: d 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, ail copies of medlcal waste rds shau b% kept on file at eneratoe3 or health care professionars facility. <br /> Applicant Signature: ` <br /> Date: / <br /> Title• <br /> 9-- <br /> Do Not Write Below This Line <br /> Q.E.H.S. Application Approval: <br /> 6,4_j� <br /> Date: Z / Expiration Date.- 12.131 1Q_2—_ <br /> E:i4502 10-03-96 Date Paid 12/ 21 (circle) Acct <br /> / Cash or Check <br /> 3q 11 <br />