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SanQaquin County Public Health Servic.,, <br /> Environmental Health Division ° EFE� D <br /> Medical Waste Management Program <br /> JAN 14 2003 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> ENVIRONMENT HEALTH <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management AP,WT/kWPI S <br /> r conditions must be mere <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> 'han 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 fallowing: <br /> i- 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 S67 FEE 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 /> ❑ NewRenewal Hottsecalls Home Health Agency <br /> 4568 Feather River Dr., Ste C <br /> Medical OfficelBusiness Name: Stockton, CA 95219 <br /> Medical office/Business Address: :ode: <br /> City: to T r — 6l <br /> Contact Person: �S <br /> Storage Facility Name: <br /> Storage Facility Address: State: Zip Code: <br /> City: <br /> i�� Q • S to 9i�c <br /> Permitted Treatment Facility Tarte: <br /> Permitted Treatment Facility Address: State: p Code: q 6 <br /> City: <br /> horized to transport the medical waste. if not enough space, attach information. <br /> +est ail employee names and titles aut <br /> Dio�P►v Til e: OLD ` <br /> 1- Name: Tit e: 4 - <br /> 2- Name: Title: <br /> 3- Name: <br /> t6 <br /> employee's pons at all times while tmnspordrig medical waste. In <br /> A copy of this exempd n nd a trackin doc steal! be in employ �osial,s facility. � <br /> addition, all les of cal a be kept rile at gee rs a cam profess <br /> i <br /> Appli ignature: / <br /> rrl I�n at ate: <br /> Title: <br /> Do Not Write gefow This Line <br /> I <br /> Approval: Date: 1 1 Expiration Date-- 1 1 <br /> 2.E.H.S. Application App (circle) Acct <br /> EH4502 16-03-36 Date Paid / / � Cas), or ec` <br />