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San Jftin County Public Health Service* Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION I To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act,% the 'following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less zhan 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE-THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services Envitonmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information 0 New %* Renewal ,Medical Office/Business Name: ,4IMerf'CAAj hie llt4l 1�P<-je(2ws e- Medical Office/Business Address:—C^l �f 4':4s f- 4,',,J -54fZ 's4eee-*7— City: 'State: -Z:,o Code: c?Y2 j2,A Contact Person: D AT77 Phone-r"r-q41s-- IS-4 - Storage Facility Name: AMM'CA to Me r (,a I 1e 5 19av-i fr Storage acility Address: C` it Zip Code: 4 12 C h State: 2 Permitted Treatment Facility Name: 6'4fe.Lrl1C1t 1 v C Permitted Treatment Facility Address:_g_17..�- -ee'r City: y r 1L1,2 A/ State: C4 Zp Code: 0 List all employee names and titles authonzee)da transport the medical waste. If not enough space, attach information. I- Name: gee Tide: 2- Name: T-itle: 3- Name: Tide: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition, all copies of medical waste n3I ma be kept on file at generatoes or health care professional's facility. Applicant Signature: Title: N,9 4 1140 r /0,7 0 .&LrAerAj Pac-At We .1 Date: Do Not Write Below This Line i. JR-E.H.S. Application Approval: Date:1Z-r7C1 01 Expiration Date: EH4502 10-03-96 a Date Paid Cash or Check (circle) Acci:-424-1�