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\4 San`.rdaquin County Public Health Sery p F Environmental Health Division 's n Medical Waste Management Program SEC 4 lye' �� jSyklt�'� 1+liL� APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTiO t To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac',O, the following conditions must be met The generator or healthcare professional generates less than 20 pounds or medical waste per week, transports less te at any ane time. maintains a tracking document pursuant to Chapter 6. and the than 2C pounds c; medicl was generator or parent organization has on fie one of the fallowing: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. - Information Document if the generator or parent organization 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 ` Medical Waste Hauler Information New J�X Renewal Medical office/Business Name: ° Med icai office/Business Address: state: a Zip Code: a ti��— 4 City: Phone oo M Contact Person: k Storage Facility Name: Storage Facility Address: City: Lo State: Tin _Tip Code: Permitted Treatment Facility Name: Permitted Treatment Facility Address: oad— State: r h Zip Code:o r,:7 a City: 1I ist all employee names and titles authorized to transport the medical waste. if not enough space, attach information. Nzm e: Beth Blit Tide:j�ai c �Pred Nurse / rl i n_Le M9 �- Title:Merj 2- Name: Maria Khan Title: 3- Name: Teri Flores A copy of this exemption and a tracking document shall 6e in employee's Possession at all times whiti�onat Porting med+�'a�• 1n } addition, all copies of medical waste records shall be kept on file at generators or health care prof f ,applicant Signature: / I / l Title: Date- Do Not Write Below This Line, Date: ! / Expiration Date: � I � ZR.E-H.S. Application Approval: j ��cr� I �� -(circle) Acct ` EH45a2 16.03-9fi Date ?aid / I �Z h °r�' { _ !