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Sa '*Environmental <br /> aquin County Public Health Sery <br /> Health Division <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 /> 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 /> ❑ New l] Renewal - 1999 <br /> Medical Office/Business Name: DAIMERON HOSPITAL ASSOCIATION <br /> Medical Office/Business Address: 525 WEST ACACIA STREET <br /> City: STOCKTON State: CA Zip Code: 95203 <br /> Contact Person: MARK G. KOENIG Phone #: (209)944-5550 <br /> Storage Facility Name: -same- <br /> Storage Facility Address: <br /> City: State: Zip Code: <br /> Permitted Treatment Facility Name: -same- <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> **See listing attached. <br /> 1- Name: Title: <br /> 2- Name: Title: <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 /> addition, all copies of medical w to retards s be.k t on� .rile at generators or health care professional's facility. <br /> 1 <br /> Applicant Signature: 1 <br /> Title: Safety Officer A Date: 11 / 30 / 98 <br /> Do Not Write Below This Line , <br /> R.E.H.S. Application Approv t i` ` ?L`( E' Date: // d Expiration Date:a <br /> EH4502 10-03-96 Date Paid / / Cash or Check #J�_t7-I_(circle) Acct <br />