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e3n Joaquin County Public He ;ices <br /> Environmental Health D1 Ion <br /> 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 /> 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 /> - 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 C(OF)IV <br /> / Medical Waste Hauler Information <br /> El New ❑ Renewal <br /> Medical Office/Business Name: wt 54U <br /> Medical Office/Business Address: <br /> city: State: <br /> Contact Person: I iJ( Zip Code: LO <br /> Phone #: (x1 U • 3 3toa <br /> Storage Facility Name: _ (1oy nt.rl Jr)f-t� �-t�d-bCcc •p,�,� S <br /> rw <br /> Storage Facility Address: I <br /> City: State: <br /> Zip Code: �( <br /> Permitted Treatment Facility Name. <br /> PermitteckTreatment Facility Address: <br /> City: S^rr�^,i .�,,,tf -Ir—�, - _ � State: , <br /> Zip Code: <br /> List ail employee ames and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: � ,�ra 1( ' <br /> 2- Name: Title: (� <br /> 3- Name: Title: <br /> I Title: <br /> A copy of this exemption an tra' i ocument shall be in employee's possession at all times while transporting medical <br /> addition, all copies of medic ords shat kept on file at generator's or health care professional's facility. waste. In <br /> Applicant gn ure: J/ <br /> Title: ' <br /> Date: / / <br /> Do Not Write Below This Line ' <br /> R.E.H.S. Application Approval: r <br /> Date: 7�^Expiration Date: �-1 3/ <br /> EH4502 10-03-96 Date Paid / / .?E4 yf Cash or Chec 4.5-4 q <br /> (circle) Acct <br />