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- -- - - -- ---------------------------------------- <br /> 2-02-1998 3:34PM Vo <br /> • P. 2 <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT100 <br /> To qualify fora "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 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave C(OPY <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> El New Renewal .� <br /> Medical Office/Business Name: C �. <br /> Medical Cf jce/Business Address: <br /> City: 6 D 1 Sta Zip Code: <br /> Contact Person: 0 LE W7015/+,t43 Phone &-,5-- <br /> Storage <br /> oStorage Facility Name: Of4 T,4 a s C At_ 4f 7Zr <br /> Storage Facility A dress: <br /> City: D b l State: Trp Code:^ O <br /> Permitted Treatment Facility Name: zv ;FS g A-%� ,�V j I-:7A 1'�A , <br /> Permitted Treatment Facility Address: <br /> City: 0 A-K LA- r2_ 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: 0 L Ko S pT— ---'t'ritle: <br /> 2- Name: Title: <br /> 3- Name: + Ll 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 waste Mords shall be kept on fie at aratoc' or health care professional's facility. <br /> Applicant Signature: <br /> Title: Date: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval. Date: q /OFxpiration Date:1 / <br /> !� l <br /> EM4502 10-03.96 Date Pai _�-{ -/ �� Cash or Check °� {circle} Acct:tV <br />