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V <br /> San quip County Public Health Servift <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 following <br /> conditions must be met: <br /> T he 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 /> PkA <br /> San Joaquin County Public Health Services 2.g-4- <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 EXRenewal-2000 <br /> Medical Office/Business Name:. DAMERON 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)944-55 0 <br /> Storage Facility Name: -same- <br /> Storage Facility Address: <br /> City: State: Zip Cade: <br /> Permitted Treatment Facility Name: -same <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> � 9pYll�l�ill <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name listing attached. Title: <br /> 2- Name: Title: <br /> 3- Name: Titre: <br /> A copy of this exemption and a tracking Vocument shall ba in employee's possession at all times while transporting medical waste. in <br /> addition, all copies of medical r kept on file at generatoes or health care professional's facility. <br /> r J <br /> Applicant Signature: i <br /> Title: SAFETY OFFI ER Date: 12 /15 / 99 <br /> Do Not , -te Below This Line <br /> R.E.H.S. Application Approval: alu., <br /> ! Date: I Z / Expiration Date: <br /> EH4502 10-03-96 Date Paid t/ / Cash or CheckT (circfe) Acct <br />