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02522/2000 14:44 2094682072PUBLIC HEALTH SERV PAGE 02/04 <br /> H16 40 P 2 <br /> San Joaquin County Public Health Services <br /> Environmental Health DMsion <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quaray Hauling Exemption'Pursuant to the"MWXcai Waste Management Act",the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 24 pounds of hood"waste per week, trsnsportr.less <br /> than 20 pounds of medical waste at any one time, muintakts a traWns document pursuant to Chapter a. and the <br /> generator or parent organtzaWn herr on file one of the following: <br /> I. Mectical ftste Man8gement Plan It tree generator or parent oVa nkagon is a large quantky generator or a smal <br /> WMIRY praeraW ragtked to register pursuant b Chapter 4. <br /> 2 In'br"01yon Document it the generator gr Parent O%anrzadon to a small quantity generator not required to <br /> regi$W pursuant to Chapter 4. <br /> PLEASE COMPLEM THE INFORMATION BELOW AND MAIL WITH X07 FEE-W.- <br /> San <br /> tri:Shirt Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stocfon. CA 95202 <br /> O New❑ Renewal Medical Waste Hauler Inkrmation <br /> Meci(cat 0IIrlrsv8ustnec>r Name: l ` E� <br /> Medical ,oaBu8iner1dress: <br /> Contact Person �ta� ap Cod®: g 65 _ y <br /> Stomps Facility Name: <br /> S#oraga Fae ft Address: <br /> City Coca' sa o5-a_o_ tia_9 <br /> Pemtiitttadd ty Treemont Faa Name: <br /> tBn <br /> city. ( �V, 1� Facility Address <br /> State: p Code:_ U!44 n <br /> List all tmPloyes names and W"ni authorised to transport the medical waste. if not oxwo spate; atter infommlon. <br /> I- Natme. 3GE- <br /> 2- Name: . <br /> 3- Nam: °' <br /> Title: <br /> A SPY or tlrls axomoon and r traarar is deaagent shag be in snpitoyes'a P low at on Uana weft banspeoft modiow wpny. in <br /> adofte,ale Copus or nteblGa M recort4 shag be Root on IUs st araerseor's ar too"goo prosalamwo finw. <br /> Appl Signature: <br /> Title <br /> Do Not Write ge)ow This Line <br /> R.E.H.S.Application Approval: Date: a iration rj-9 <br /> Ftr4302 10.03-% Date Paid cah or Chock# (Circle) Arc <br />