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' •' Sar,,.,;aquin County Public Health Servic; <br /> < ,ca,L„ <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 /> 3_ Medical Waste Management Ran if the generator or parent organization is a large quantity generator or a small 1 <br /> quantity generator required to register pursuant to Chapter 4. <br /> .t <br /> Z_ Information Document if the generator or parent organization is a small quantity generator riot required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH 567 FEE T0: D <br /> San Joaquin County Public Health Services DEe <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 4 �Ji�[3f ily, fid1 , ALT4 <br /> 304 E Weber Ave p��k�l�jS1liCES <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> C3 New M Renewal <br /> Medical OfficelBusiness Name:. KING FAMILY C N <br /> TPIP <br /> Medical Office/Business Address:_Z640 F a f State: C A Zip Coder 0 7 _ <br /> City: Stockton Phone ': fl9 / 944-4150 <br /> Contact Person: <br /> i Storage Facility Name: <br /> Storage Facility Address: 7 01 ppt. <br /> State. C A Zip Code: 9 5 2 0 2 <br /> City: <br /> permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: State: LA Zi Code: 95742 <br /> P <br /> City: or <br /> List all employee names and titles authorized,to transport the medical waste. if not enough spare, attach information. i <br /> 7Ue: o o r d r}+ <br /> 1_ Name: Title: <br /> 2_ Name: T r r ' P Title:M d ' A <br /> 3- Name: Vick S e q u r a <br /> times while <br /> A copy of this exemption and a tracking document shale man file at gen tin employee's o possession <br /> ar�heaith-all <br /> ars professional transporting <br /> � � In <br /> addition, all copies of medical waste records siraq he kept { <br /> Applicant Signature: <br /> Date:. / <br /> Title: <br /> Do Not Write Below This Lire <br /> A. +plication Approval: Date: 1 D 10 Expiration Date: <br /> Date Paid —•X:Q !�� l� Cash a (circle) Avert <br /> EHa;(12 14-03-96 <br />