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San Jouin County Public Health Service <br /> Environmental Health Division <br /> yam, 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 Act', the following <br /> conditions must be met: <br /> T he 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 Pfan 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 S67 FEE 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 /> NewY Renewal <br /> Medical Office/Business Name: 1:).EL 1"t4 X4-1(6 Lo 11 s c2 , <br /> Medical Office/Business Address: L <br /> City: State: l Zip Code: <br /> Contact Person: 0r S'7" ��— Phone '„?o� <br /> Storage Facility Name: ja j?A-L• :�j C7 R f7. Tif/C U%.v k S d zr�_t c Lel <br /> Storage Facility Addrgss: <br /> City: L O D /� State: {F— Zip Code:� <br /> Permitted Treatment Facility Name: " dAIlK 5 <br /> Permitted Treatment Facility Address: ! <br /> City: 43 AL'C1 A-h/© State: Zip Code: o <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: � K . © 1 t Title: <br /> 2- Name: Lladz c Title: <br /> 3- Name: L_c R R t -r= �� i' I- I S _ Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times white hansportinq medical waste. In <br /> addition, all copies of medical waste ords shall be kept on file at g ratoes or health caro prafesslonars facility. <br /> Applicant Signature <br /> Title: — Dater <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date:Pn&20/22 Expiration Date: 01 P-000 <br /> EH4502 10-03-96 Date Paid IA'l !0 / / Cash or Check * 3 �_(circle) Acct <br />