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r NI-30-1998 <br /> i-30-i998 2:43PM r P# <br /> San Joaquin County t Public Health Sloices <br /> Environmental 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 foilowing <br /> conditions must be met: <br /> ical waste per week, <br /> nsports less <br /> The generator or health care professt an 1 one time, maintains generates less than za tracking docu0 pounds of ment pursuant to Chapter 6 and the <br /> than 20 pounds of medical waste a y <br /> generator or parent organization has on file one of the following: <br /> I_ Medical Waste Management Plan if the generator or pr organization is a large quantity generator or a small <br /> o <br /> quantity generator required to register pursuant Chapter 4 <br /> 2- Informat/on 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 [PY Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> • Medical Waste Hauler Information <br /> ❑ New Z Renewal <br /> Medical Office/Business Name: DAMERON HOSPITAL ASSOCIATION <br /> Medical Office/Business Address: 525 WEST ACACIA STREET late: Zip Code: 95203 <br /> STOCKTON Ste: CA <br /> city, Phone #: (209)944-555C <br /> Contact Person: MAS . KOENIG <br /> Storage Facility Name: <br /> —SAME— <br /> Storage Facility Address: State: ZIP Code: <br /> City: <br /> Permitted Treatment Facility Name: -SAME- <br /> permitted Treatment Facility Address: State: Zip Code: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach informatics <br /> —SEE ATTACHED LISTING— Title: <br /> I- Name: Tide: <br /> 2- Name: Title: <br /> 3- Name: <br /> of this exemption and a eking ocumen shall be in employee's possession at all times while transporting medical waste_ <br /> A copy at generator's or health care professionaft facility. <br /> addition, aL <br /> mediea��f reg shadp <br /> Applican : I pate. 02 / 12 98 <br /> Title: SFFICER <br /> Do Not Write Below This Line <br /> Date:�O /f Expiration Date- !y. <br /> R.E.H.S. Application Approval: (circle) Acct <br /> EH4502 10.03-96 Date Paid / Cash or Check #-'-�" <br />