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�jV <br /> San Joaquin County Public Health Se*s - <br /> Environmental Health Division JAN 15 2002 <br /> Medical Waste Management Program <br /> ENV('R,0#k�pgiNTHEALITFf <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEl ERVI:C,ES <br /> To quality for a "Limited Quantity Hauling Exemption" pursuant to the 'wedicai Waste Management Ac:', the following <br /> conditions must be met: than <br /> s of medicai waste <br /> i ne generator or health care professional generates mainins2a tiGc`•aag docent pursuanero � transpp tr 6,03 l <br /> ess <br /> rateless <br /> dthe <br /> 'hon 20 pounds of medical waste ata y <br /> generator or parent organization has on SIe one of the following: <br /> _ Medica! Waste Management Plan if the generator or parent orpursuant to Chapter 4. <br /> ganization is a large quantity generator or a small <br /> quantity generator required to register <br /> t organization is a small quantity generator not required to <br /> information Document if the generator or paren <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 Fc�TOr"'c <br /> : <br /> San Joaquin County Public Health Services <br /> nvironmental Health Division JAN 1 2002 <br /> Medical Waste Management Program <br /> 304 E Weber Ave COMMUNITY MEDICAL <br /> Stc&ton, CA 95202 CENTERS IN <br /> Medical Waste Hauler Information <br /> NeN <br /> E,!/'Renewal <br /> K 1 l <br /> Medical Office lBusiness Name: F� c F <br /> Medical Offrlc2/Business Address: d U State: 4 Zp Code: <br /> S Phone <br /> City: -I IC` t.v <br /> Contact Person: <br /> Storage Facility Name: Gk iAt� t_ <br /> — L <br /> Storage Facility Address: State: C' Lp Code: 9 <br /> City: <br /> permitted Treatment Facility Name: ' <br /> ki.F <br /> , <br /> Permitted Treatment Facility Address: Stat: `CG1, �n� �Zp C°de: cf'�`742 <br /> X13 e-iii <br /> City: <br /> List all em loyee names and titles authorized to transport the medical waste. if not enough space, attach information. <br /> P <br /> Title: E(�i <br /> Title: <br /> 2- Name: D� A /y Tide:Ti <br /> 3_ Name: � <br /> on and a tracking document shalt be in employee's possession at ail times while t wisporting medical waste. in <br /> Acopy of this exempla <br /> professional's facility. <br /> addition, all copies of medical waste recordsshall be kept onaafife at generators or health care <br /> lV t <br /> Applicant Signature: IV �:� Date: ID- 1 <br /> Title: <br /> Do Mot Write Below This Line <br /> iration Dat- l Z/ 3/lDZ i <br /> Date: _p -- <br /> R.c.-i.5. , 1 5-7-71-7, (circle). Acct <br /> Application approval: <br /> - - tiara ?aid I2 / �- 10 — <br /> Cash or Ch ec: S_ <br />