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Joaquin County Public Health Services <br /> tp Environmental <br /> Health Division <br /> } 2 Mana e / <br /> Mw ,141edlcal W t g ment Program r- z <br /> �QPPLICA ONTO '`." . t, L _ <br /> r �R A LIMITED QUANTITY HAU <br /> To qualify foraLimited, <br /> i / } A r h ,1"; ,"N,. � i; UNG EXEN(PTION <br /> • "Liruted VL "4 <br /> condi �a v <br /> tions must be met: <br /> 9 P u{5uant to the <br /> Medical W <br /> a5te <br /> _ '� �`�;•, ,,,.:` 3��� rr��:. Management AcCf they foUov�u�g .� •�' <br /> The generator or healthcare professional generates than 20 Pounds <br /> than 20 � > <br /> Pounds o!;medic*,-,waste.at.'any one thn ` P sof medical waste <br /> generator or parent�9a ?Itlonhas on .'maintains a tracking document Plt wok transports k <br /> file one Pursuant to ' <br /> ry a of tic following: �P er 6. and the ti <br /> Aoill <br /> quantity g9e�t 1?!an the 9enetor or parent organization=t � � 5 Erni ' <br /> �. e t . . <br /> T u' reg is a iarq <br /> =If, Pu, t to Chapter 4. tY Senerator or a small2- Info rQuanb rmatlon` the generator or <br /> register pursuant gent organization is a small quantityy'generator"� .ry <br /> Chapter .d{ <br /> PLEASE COMP <br /> LETS THE INFQ <br /> RMATION BELOW AND MAIL Wl S6 <br /> San :, <br /> ET <br /> Joaquin County PublicJHealth Servtces <br /> Environmental Health'Qivision <br /> Medical Waste Mona eine <br /> nt Program <br /> 304 E Weber Ave • ` <br /> Stockton, CA <br /> `,V <br /> 4 y <br /> O New Renewal ' a-�k ," cal,Waste H user In <br /> Medical Office/ Name: <br /> i•�.j��� � - ��';";�`.� <br /> Office/Business F � <br /> s Nam <br /> Medical Officel e. f o <br /> usin k' n <br /> ess Address. <br /> City: <br /> Contact Person �uw State: <br /> zip;. <br /> �v <br /> Storage Facility. 1 <br /> Name: , <br /> Storage.Facili x. <br /> City- <br /> v. <br /> r <br /> State: <br /> Permitted Treattnen_t FaGu '' hzt `� _a <br /> Permitted Treatm " r ' <br /> City: d ent'FacJit //' N <br /> _..r ° <br /> .,• ,,.,.,,. .. State. . , , .x �.:- „�}. <br /> List all employee t Zjp_Cgda �a ;; <br /> 5 au tq to <br /> the medical waste. If not enou �� <br /> �• Name. a o'' 9��.,4 T tonna <br /> 2- {..Name: Title: r <br /> 3-: <br /> t . , Title: ;3 <br /> z Title: <br /> A copy of this exemptlon::a� i <br /> all el document sha Gt em ., " <br /> a On!, eopl of�edtcal waste shall be ke p'l s possession at all es t <br /> �. <br /> Applicant Signat on at rator+a or h al cana?aUrW <br /> r <br /> $nature `r:, re'a. D e a a <br /> Title. <br /> Y <br /> •,:0o Not' •, , Write'Below This Line <br /> R.EHSKApplictir `, rateId ux ` ate� --.. 4 npon <br /> Oate: yl <br /> or Check <br /> A Yf <br /> (circle) ~ <br /> R <br /> � o-i r• <br />