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JAN. 7.2000 4:36PN - N0.859 P. <br /> _ t <br /> Joaquin County Public Heat Se <br /> Environmental Health Division <br /> A $�� Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANMTY HAULING PTiON <br /> To qualify for o dUmited Quantity Hauling Exemption" <br /> conditions must be met Pursuant to the"dAedicat Waste Management Acl", the following <br /> The generator or health care professlonat generates less than 20 <br /> than 20 pounds of medical waste at any one 4me, maintains a ft' rids domedcurn of I 4ds�rts per less <br /> generator or parent organization has on Erle one of the following. pursuant to Chapter 6, and the <br /> i- Medtc2l Waste Management Rfan if the generator or parent ' <br /> quantity generator organization is a targe quantity generator or a small <br /> _ _ 2gtrired to register pursuant Chapter 4. , <br /> 2- Infurrrration Docume»t tf the generator or — _--- — — —-�--- -- — <br /> register pursuant to Chapter 4parent organization is a smelt quantity generator not required to — <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 j <br /> Stockton, CA 95202 <br /> �,e' Medical Was r <br /> Hauler Infomation <br /> M New o Renewal <br /> Medical Office/Husiness Name:. ' <br /> Medical Office/Business Address: <br /> City: <br /> Contact Person: State: _7k Code. <br /> l Phone;l~ <br /> Storage Facility Name: Q, <br /> Storage f=acility Address; 0 <br /> City: <br /> State: ZIP Code: <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Faaky Address: l l <br /> City: t <br /> State: aP � <br /> List all employee names and Was authortzed to transport the Medical waste. if not enough <br /> . <br /> 9 attach infa�trtation. <br /> 1- Name: <br /> 2- Name; Tltie .44 <br /> - <br /> 3- Name: 1'itfe <br /> rtle:—rtte�tr►Ln rd^ <br /> A copy of this exempdan a a traekl'Lj Y srr[, t . t <br /> addition.art copres of 1 wa0d t!c r�short be rn tntpt s ton at aft tltttee*fNre Cat rrt <br /> Q tis Capt on Mex or health Cats s facillly. <br /> Applicant Signature: ! <br /> Ttle: <br /> Oo Not Write Below This Line <br /> R.EKS.Appiicatton Approval: <br /> E7i45oZ 103-96 Date: �r-7-100txpirttitfA t?ate7�/l' /CYC •. <br /> Date Paid ! 5 h or i(circle) <br /> AccrI <br />