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° Sa oaquin County Public Health Se s <br /> Environmental F ealth Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality fora"Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the following <br /> conditions must be met: <br /> ical waste per week, <br /> rts <br /> ess <br /> The generator or health care professional generates less than 2a pounds of tracking document ant pursuant to Cti ptte o l 6, and the <br /> than 20 pounds of medical wase at any one time, malntw <br /> generator or parent organization has on me one of the following: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small pursuant to Chapter 4. <br /> quantity generator required to register <br /> t organization is a small quantity generator not required to <br /> 2- Information Document if the generator or paren <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 rcE 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 91 Renewal <br /> Medical office/Business Name: DAMERON HO <br /> Medical OfnceiBusiness Address: 525 WEST A State: CA Zp Code: 95?03 <br /> City: TO <br /> MARKRK GG.SA . KO Phone T 461-3151 <br /> Contact Person: <br /> Storage Facility Name: -sa - <br /> Storage Facility Address: State: Zp Code: <br /> City: <br /> rme Facility Name.--same- <br /> Permitted <br /> „fitted Treatment <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 information. <br /> -see attached listing- Title: <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3_ Name: <br /> cking document shall be in employee's possession at all times while transporting medics waste- In <br /> A copy of phaUbe kept on file at generator's or health care professicnars lac:Ii <br /> this exemption and a traty. <br /> addition, all copies of medlca c <br /> Applicant Signature: ��— <br /> Title: SAFETY OFFI <br /> no No Write Below This Line <br /> Date: l/p2/�y2 Expiration Date: �Z= � <br /> 71PLE.H.S. Application Approval: Cash or deck s b-I Z (circle) Acct • — <br /> EH4502 t0-03-46 Date Paid � � <br />