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an Joaquin County Public Health Sefoices <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality 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 pmfaasfonal generates less than 20 pounds of medical waste per week, transport, 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 lite one of trio following: <br /> 1- Medkel 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 ft generator or parent organization Is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLFA$E COMPLY THE IWQRMATION BELOW AND MAIL WITH$97 FEE TO: <br /> Sari 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 Informatlon <br /> © New IF Renewal Public Health Swim <br /> Medical O ffa ftt-lnass Noma: San Joaquin County <br /> Medical Office/Business Address: 11691 F- "cuVILkAl <br /> G11ty; - _ ---- Zip Code: <br /> Contoket PeTftn: <br /> Stomge Facility) flame; a is <br /> SkmVa Facility Address' <br /> City: 1601 t Hazeffon state: zip cane: <br /> Permitted Treatment Facility Name:S"' ' c. <br /> Petrnitted Treatment Facility Addres& V- tjt/ <br /> city:_��reS� atato: <br /> List all employee names and Mies authorized to transport the medical waste. If not enough space, attach MfoRnetlon. <br /> 4- Narita- Title. <br /> 2- Name: <br /> s- dame- ' Title: <br /> A copy orthts momptlon ands tracking decuma d shat be In employee%pmomian at oli tknes wpm@ tmnspaNng medlaat w4ste. In <br /> sddNtw,aatt copleRa of madlcal waste recoab shalt be kept on Me atgwwrdWs or Lamm care protmelown facility. <br /> Applicant Signature: <br /> 1417Title: -P Date: 0 1 Q.4 <br /> Do Not Write Below This tine <br /> R.E.H.S.Application Approval. CXata: -f ` 1,Expiration 1D11tr✓ <br /> aH4sfl2 1003-96 mate Paid cash or Check (circle) Acct ,---- <br />