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Apaquin County Public Health Sd" <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac;', the following <br /> conditions must be met: - <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a ticking document pursuant to Chapter 6, and the <br /> generator or parent organization has on file one of the following: <br /> 1- 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 /> ❑ New 4` Renewal <br /> Medical Office/Business Name: ✓ l <br /> Medical Office/Business Address: s <br /> City: S406 1, SOA) State: Zip Code: <br /> Contact Person" DA I/iLys � Sn f'P��� � ��� sh �N✓ Phone <br /> Storage Facility Name: A,, <br /> Storage F cility Address- <br /> City: 576 State: (° Zip Code: 9Sa 0 <br /> Permitted Treatment Facility Name: .S e r i C I <br /> Permitted Treatment Facility Address: 7 7.' E T r <br /> City: V erN4/v State: Lf- Zip Cade: �DU�3 <br /> List all employee names and titles authorized to/ transport the medical waste. If not enough space, attach information. <br /> 1- Name: 5 o 4 7 7 �/� �� /` S� Title: <br /> 2- Name: The: <br /> 3- Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition, all copies of me <br /> di <br /> cal wastq reco shall be kept on file at generator's or health care professional's facility. <br /> Applicant Si nature:C/V Coja <br /> II <br /> �i <br /> Title: t1 ti 4lr �P/2 Date: / / / / 0 a, <br /> Do Not Write Below This Line <br /> Q.E.H.S. Application Approval: Date: ! ZfrRiration Dale: /� <br /> EH4502 10-03-96 Date Paid 1 ICI / D Cash or Check T 17,6I7-ZD (circle) Acct <br />