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w <br /> P. '2 <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A'LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a°Llmited Quantity Hauling Exemption"pumuant to the"Medical Waste Management Act", the following <br /> conditions must be met <br /> The generator or health care professional ga3nerates 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 Me one of the following: <br /> 1- MedW/Waste Management Plant If the generator or parent organization is a large quantity generator or a small <br /> quantity generator requtreq 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 NAIL WITH$U PEE TO: <br /> Sart Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 F Weber Ave <br /> Stockton, CA 95202 <br /> © New*Renwwal Medical Waste Hauler lnfiormatlon <br /> Medlcal CNficeJ-usfness Name: ` <br /> c <br /> Medical Office/Buaines®Address: 0 1 u <br /> City: , <br /> Contact Parson: State: a Code: <br /> , <br /> a r ' Phone#:, � <br /> 1 <br /> Storage Facltity Name: <br /> Storage Facility Address' y <br /> city: <br /> Permitted Traatrnent.Facility Name: <br /> Permitted Treatment Facility Address: _ <br /> city. -tate:_ dip Code: <br /> List all employee names and titles authorized to transport time medical waste. If not enough space. attach Information. <br /> 1- Name- '2. Name: 4:�2� <br /> Two: <br /> 3- <br /> Name: Ilde, <br /> A copy of this Oxemption and a tracking doownent shall be in employ",*oo"e atorl Lt all tfrosN wtaile transporsn8 maAl�t warts. In <br /> addition,a1!e4ples of nwdi t uvaVo re"Ido shall be kept on file aatgeriwralor's or t"ith caro prafessionat'e•facility. <br /> Applica iture: <br /> Titls: <br /> Do Not'Write Below This Line <br /> R.E.H.S. Application Approval: Date: 6 7f V prcpiration pate: (' � <br /> reaz mau3-5e ®ate Paid Cash or Check 0.(circle) Acct <br />