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Saneaquin County Public Health Servi <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING PTION <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Ac', the following <br /> conditions must be met <br /> T <br /> e 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 tracking document pursuant to Chapter 6, and the <br /> generator or parent organization has on 51e 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 $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New 0 Renewal <br /> Medical Office/Business Name:.AM a r_ ('CA au hie .'z.41 Q e 2,,v S r- <br /> Medical Of�fice/Business Address: !R �f !=A$ k®'N d s g le S 4 e e t-r <br /> City: t h 4on/ State: C/_I __Zip Code: c15- <br /> Contact <br /> !SContact Person: RA e rr- Phone;"F gds-- yS-4 07.? <br /> Storage Facility Name: rig AlP i C I �.Vvov_if. <br /> Storage facility Address: <br /> City: C�1 �uti State: Zip Code. Sia U <br /> Permitted Treatment Facility Name: !e; c u c/e JN C <br /> Permitted Treatment Facility Address: a -1 7S` /:a s T o n;ti S e e r <br /> City: !e✓' ti Q IV State: . CA Zip Code: 9vd a?3 <br /> L ist all employee names and titles authorized o transport the medical waste. If not enough space, attach information. <br /> 1- Name: 4-Lllelh ! , Title: <br /> 2- Name: Title: <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 medll n3 be kept on rite at generators or health care professionars facility. <br /> Applicant Sigpature: <br /> Title:�i/d r l lr,v pu`,*,°;c �2 e�i v�v S� e ` �t� ��`s c, r Date: d / i� / -1 <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: �Oate: 2/�/ Expiration Date: Z/-3/ � <br /> / <br /> EH4502 10.03.96 Date Paid J2 / 2.o / df Cash or Check (circle) Aat <br />