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07/02/2002 109:43 209460 <br /> FIFTH FLOOR ft PAGE 02 <br /> San Joaquin County Public Health Services <br /> Environmental 4alth Division <br /> Me4ical 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 /> Tine generator or health care professional generates less than 20 pounds of Medidal waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains-a tracking document Pursuant to Chaptdr S. and the <br /> generator or parent organization has an ffle one of the fallovAnT.. <br /> I- Medical Waste management Plan if the generator or parent organization is a large quantity generator or a sm2ll <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- information Document if the generator dr parent organization is a s.nali quantity generator not required to <br /> register pursuant to Chapter 4. CE� <br /> PLEASE COMPLETE THE INFORMATION BELOW AND.MAIL WITH $67 FEE TO: <br /> San Joaquin County Public Health Services JUL 2 9 2002 <br /> Environmentar Health Division ENVIRONMEW HEA <br /> Medical Waste Management Program PERMITISERVIC LTH <br /> 304 E Weber Ave ES <br /> Stockton, CA 95202 <br /> Medical Waste I-ladler Information <br /> MNew 0 Renewal <br /> ............. ...................... <br /> Medical Office/Business Name:. <br /> ,Medical office/Business Address: <br /> Zip Co�de �6 <br /> State: p Code: 1b% <br /> City: Phone <br /> nc <br /> Contact P rson <br /> Storage Facility Name: <br /> s- <br /> 7 <br /> Storage Facility Addresi -State:late. <br /> C& �Zip Cade: 9 <br /> City: <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: State: CO— ;np Code: <br /> City:- <br /> e'medical waste. If not enough space, attach information.L�ist all employee names and Wes authorized to transport th <br /> Title: <br /> Name:_ Title: <br /> 2-- Name: <br /> Title: <br /> 3- Name: <br /> =a be in emplaye4es possession at all times while transporting medical waste. In <br /> A copy of this. ex,emption and a tracking document shag file at Seneratoes or health=re pmfessiottars facility.addltlamaili copies of me"I wa=recortIss be kept on <br /> Applicant Signature- Dare.• -7 <br /> Title: rTA� <br /> 00 Not Write Below This Line, <br /> Date:3:13t/C)ZjKpiration Date.--JZ�l I <br /> .Z.E.H-S. Application Approval A� <br /> Date p4aiid4. 0 �h or�Ch�&� - _ O (circle) Acctjlf�—.— <br /> EH4502 10-03-96 <br />