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Sanuin County Public Health Servic <br /> Invironmental 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 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 Fr-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 /> 0 New Renewal <br /> Medical Office/Business Name: 1),15L-7A- `A0A 0/o L 0 </. j&4 jg�-0., `cif/ <br /> Medical Office/Business Address: S — <br /> City: [, State: CG Zip Code: <br /> Contact Person: e (=— dA -T— Phone <br /> Storage Facility Name: I? 12 <br /> Storage Facili dress:2 'IV= C s - <br /> City: i d ® 4�! State: Zip Code: <br /> Permitted Treatment Facility Name: 'rS S I <br /> Permitted Treatment Facility Address:oft?t 1—&ft,/l7 State: .52,,Q= Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: 0 ^ t 6 4LS 7—i ;07- Title: /4- lP. ELI <br /> 2- Name: Title: ^'t <br /> 3- Name: C1 L t 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, all copies of medical wastevIcards shall be kept on file at eneratoes or health care professional's facility. <br /> Applicant Signature: 4L <br /> Title• e, Date: 1 / / ® f <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date:a/ /D Expiration Date: <br /> EH4502 10-03-96 Date Paid 1 ,5-l OI Cash or Check T /D:2 3 tcircBeD Acct /�o�c_ <br />