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San oaquln County Public Health Servi -d Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent pursuant to Chapter 4 ganization is a large quantity generator or a small quantity generator required to register 2- information Document if the generator or parent arganization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Mbdical Waste Hauler Information ❑ New IS Renewal Medical Office/Business Name: DAMERON H S Medical Office/Business Address: 525 WEST ACACIA STREET State: CA Zip Code: 95203 City: STOCKTON 461-31-_ � Contact Person: MARK G. KOENIG Phone #r: 51 Storage Facility Name: -same- Storage Facility Address: State: Zip Code: City: Permitted "treatment Facility Name: -sa - Permitted Treatment Facility Address: State: Zip Cade: City: List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. *see attached listing* Title: 1- Name: Title: 2- Name: Title: 3- Name: A copy of this exemption and a tracking document phall be in employee's possession at all times while transporting medical waste. in addition. all copies of medical reco sha e e t on file a"eneratoes or health care pmfessioeral's facility. Applicant Signature: Dace: 12 / 2L--!-OD— Title: 6 /nnTitle: SAFETY OFFI Do Not Write Below This Line Q.E.H.S. Application Approva . Date: f�Expiration Date• IZ/3/ 10-1 EH4502 10-03-96 Date Pai l a a'l U J Cash or eck �lad-0�(circle) Acct .