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4-28-109,9 10:S2AM FROb#- P. 3 <br /> San Joaquin County Public Health Services <br /> Environmentai Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITYHAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" purstrant to the Weescal Waste Management Act", the following <br /> conditions must be met <br /> The generator or health care professionai generates fess 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 fouow <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 serail quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE TrlE 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 /> EkNew ❑ Renewal <br /> Medical OfficsiBus ness Name: Manteca Gnif <br /> Medicai Of;:ceJ8usiress Address: Post Of Tice Box 32 <br /> City Manteca State: CA Zp Code: 95736 <br /> Contact Person: Betty Ingell, F.N.P. , Ed.D. Phone X09-82 ext.780 <br /> Storage Facility Name: Manteca unT Tea school District <br /> Storage Facility Address; 2901 East louise Avenue <br /> City: Lathrop, CA 95330 State: UA Zo Code' <br /> Pesr�ited Treatment Facility Name: Integrated Environmental Systems <br /> Permitted Treatment Facility Address: <br /> Cly, Oakland State: Zip Code: <br /> List all employee names and tides authorized to transport the medical waste. If not enough spate. attach 'information. <br /> * See attachment <br /> 1- Name: True: <br /> 2- Name: Titter <br /> 3- Name: Title: <br /> A espy of this exemption ern! a=C" document shalt be in GMPIDYGWS n at aA tittles while ttal ordng medk=A waste. tee <br /> addition, all espies of m mcords stmO be kept on fire at or healt5 cam Wnaft bea7ily <br /> Applicant Signature:,,- <br /> Date: 081 31 / 98 <br /> ten„ Do Not Write Below This Line <br /> 9 l <br /> 3. S. Apgl i �n App Date: /-/,L /9�Ezpitation Dat =19/ <br /> D44502 10.03-% Date Paid a 7 Cash o C�f yl3g!y (circle) Accr P OT8 <br />