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Sal oaquin County Public Health Servile 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 $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information ❑ New ❑ Renewal Medical Office/Business Name: 5L-r C71 o L c " /tit Pi G L ti �'- Medical Office/BMp ess Address: City: " State: CIE Zip Code: Contact Person: n Fa i Phone #:Lt. Z. Storage Facility Name: E-J-T-A- R A-D i o L��`l M 001 C a L i� P V,,, N I<` S T 9 Storage Facility Address: taJ — l City: 6 0 i' State: - Zip Code: Permitted Treatment Facility Name: "r /fi 7- X_��' f F D 10"Cl V �•(A S Permitted Treatment Facility Address: 1 Sit S"ice' City: n )Zk-K I- A-,t/> State: C Zip Code: c� List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: © . tC • KO J54,Lt s—( 115 1�! Title: r`� /- /Z I 2- Name: �f/ c�i t3 r7C_0 „ Title: l`} IZ T 3- Name: D t2 i KV L i t Title: (I- A ZA 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 re��rds shall be kept on file at generator's or health care professional's facility. Applicant Signature:__ �C c.�•� Title: Date: l �i-i J `l Do Not Write Below This Line R.E.H.S. Application Approval:— 1 �yi _Date: IZ/i 1"/q hxpiration Date:/2 /-3/ /51 EH4502 10-03-96 Date Paid j �/ /A Cash or Check # (circle) Acct 4i