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Sdooaquin-County Public Health SerSs <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOA 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 /> 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 /> 11- 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 <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 N4'Renewal 7 <br /> Medical Office/Business Name: <br /> Medical 0 1 /13upirless Address: <br /> City: State. Zip Code: 93-2_ <br /> Phone <br /> Contact Person <br /> Storage Facility Name: <br /> w <br /> St Address: <br /> Ci _ state: L�' -Zip Code: <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: State: Zip Code: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name:,, Title: <br /> 2- Name: <br /> 3- Name: 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 /> at generator's or health care professional's facility. <br /> addition, all copies of al waste records shall be kept an file <br /> me records shall e <br /> Applicant Signature. <br /> Applicant Signature. <br /> Title: Date: <br /> Do Not Write Below This 4ine <br /> —Date: /CbExpiration Date [2-1 <br /> R.E.H.S. Application Approval:___ <br /> EH4502 10-03-96 Date Paid b-5 /00 Cash or (;keck ___.Llo_13 (circle) Acct <br />