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4W%. Joaqtjin County Public Health ices <br /> Environmental Health Divisi <br /> MAV <br /> edical Waste Management Program <br /> APPLICATION FOR A COMMON STORAGE FACILITY PERMIT <br /> A Common Storage Facility is utilized for the collection of medical waste produced by <br /> small quantity generators operating independently, but sharing the same "common" <br /> storage area. pP <br /> PLEASE COMPLETE THE FOLLOWING AND MAIL WITH APPROPRIATE FEE(SE 4:d-CATEGORIES) TO: <br /> San Joaquin County Public Health Services H, .L-jV-1H -WiN311 <br /> Environmental Health Division 000Z 9 0 <br /> P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> PERMIT MAY ONLY BE OBTAINED BY COMMON STORAGE FACILITY FEE <br /> ONE OF 7 4E FOLLOWING (CHECK ONE): CATEGORIES {CHECK ONE): <br /> Y HEALTH CARE PROVIDER 2-10 MEDICAL OFFICES =$134 <br /> 0 MEDICAL WASTE HAULER 1-50 MEDICAL OFFICES = $265 <br /> PROPERTY OWNER 0 51+ MEDICAL OFFICES = $473 <br /> PROPERTY MANAGEMENT FIRM <br /> Name of Permit Applicant: 3fockLjaL-L&�e5tLLaZ Ce- Phone #:o?O� IK7--3 gZ" <br /> Address of Permit Applicant: &z f- ,�L 4 le, l�--3 <br /> City: vvc-L&& T— -State: Zip Code:-25�207 <br /> Contact Person: C,21 <br /> ,�j Phone *cW-9 V -39elb <br /> t,o Title: -7e <br /> Common Storage Facility Address: 6E22 d0a <br /> City:_Skc-tl6o ' State:_ CR Zip Code: ZJ207 <br /> PLEASE LIST BELOW THE NAMES OF THE OTHER SMALL QUANTITY <br /> GENERATORS WHO WILL SHARE THE COMMON STORAGE FACILITY(IF MORE THAN <br /> 5 ATTACH INFO): <br /> 1)Name: Fe' (- W 14 Address & Suite A <br /> 2)Name: L9 MM"CSM . Address & Suite <br /> 3)Name: Address & Suite <br /> 4)Name: K 61m 0� 4iZCe 61-C' Address & Suite <br /> 5)Name: ke ul A-' Address & Suite <br /> Applicant Signature:_ Title:— Date: <br /> R.E.H.S. Application Approval: —Date: <br /> EH 45 01 09-27-95 <br />