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A-Li8-1998 10:S2AM FROM P. 3 <br /> San Joaquin County Public Health Services iD1a7`rf <br /> Environmental Health Division <br /> Medical Waste Management Program K <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 tracKng 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 <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> Ek New ❑ Renewal <br /> Medical Office/Business Name:. Manteca Unified School Di.5trir-t <br /> Medical OfiicJ-Susiness Address: Post office sox 32 <br /> City. Manteca State: CA Zip Code: <br /> ContactPerson: Inge F.N.P. , Ed.D. _Phone t 20_ 9-825-3 -00 ext.780 <br /> Storage Facility Name: Manteca unified School District <br /> Storage Facility Address: 2901 East louise Avenue <br /> City: Lathrop, CA J533U State: UA Zip Code: 95330 <br /> Permitted Treatment Facility Name: Integrated Environmental Systems <br /> Permitted Treatment Facility Address:._„_4g.�.�s.±__ c+ p �.. ._-,.._ <br /> City: <br /> Oakland State: Code: <br /> List all employee names and titles authorized to transport the medical waste_ If not enough space, attach information. <br /> * See attachment <br /> 1- Name: Title: <br /> 2- Name: Tide: <br /> 3- Name: Title: <br /> A copy of this exemption and d tracking doeument shall be in employee's possession at all times white transporting medical waste. In <br /> additio4 all copies of rned records shall be kept on file at senemtor's or healttf carie professio+tal's faeillty- <br /> Applicant Signature: <br /> rt <br /> Date: 08/ 31 / 98 <br /> - <br /> ILB/1. <br /> Do Not Write Below This Line <br /> pArn,r%1,- 'r, — " ) <br /> 41-5- Applicriti n ApprO Date: I _L__Expiration Date: I l <br /> EM4502 1"3.96 [)ate Paid /D /a 7 / b' Cash o CChecc q (circle) Acct_ Alf e Z?48 _ <br />