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s4lbAQUIN COUNTY PUBLICHMT4�ERVICES <br /> ENVIRONMENTAL HEALTH DIVISION U Medical Waste Management Program PC <br /> PLICATION FOR A Ll D IQU G ON�Ty.� . <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste <br /> Management Act", you are required to meet the following conditions: <br /> 1- Your medical office/business generates less than 20 pounds of regulated medical <br /> waste per week. <br /> 2- Your medical office/business transports less than 20 pounds of regulated medical <br /> waste at any one time. <br /> 3- Your medical office/business maintains records of any regulated medical waste <br /> transported offsite for treatment and disposal, including the quantity of the waste <br /> transported, the type of the waste transported, the date the waste was awisported, <br /> the name of authorized person that transported the waste and the destination of the <br /> waste. <br /> PLEASE COMPLETE THE INFORMATION B d$�67APKUCATION FEE <br /> TO: <br /> San Joaquin County Public Health Services 1� <br /> Environmental Health Division <br /> 2 1 �g�32 <br /> P.O. Boa 2009 <br /> JAN utN ®UNTO <br /> St on, CA 95201 ,aN 3OR�T <br /> PU81.tC -cAt_NE.��-.N <br /> Medical Waste Hauler Information-Nva <br /> Medical Office/Business Name: e• C ua Cr V- 44tn . <br /> Medical Office/Business Address: (ISS L-:S c fi t�cn 1,1VC <br /> City: E3ccllwState: ! d Zip Code: �i 5 3 <br /> Contact Person: H m, u(vnQr bvm Ku Ct'l. c. i t t `ra--mf2 Phone #: L- e2 j s 3 k- 7&,Jc <br /> Permitted Treatment Facility Name: At 1 Permit #: x/14 <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name: Max -Cd rig e v- Title: f v v ( oL. -- <br /> 2- Name: Kart,-• Lj?,t t i ct.ns Title: ® e_ L±cLkic- <br /> 3- Name: `i"i,P_cL Lu 134t5, 5 Title: dss csfa a In c s M ccnc � <br /> If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian <br /> or home health care nurse transporting medical waste back to own facility,please complete the following: <br /> Storage Facility Name: Es c,50 y= At. Permit : N/A- <br /> Storage Facility Address: I 115 c ! Uro 4,ye <br /> City: Eflct cr i State: CR' Zip Coder 5 3Z�V <br /> A copy of this exemption and a tracking document containing the Information above shall be In <br /> employees possession at all times while transporting medical waste. In addition, all copies of <br /> medical waste re?oyds shall be kept on fit ur facility. <br /> Applicant SignatorZTitle: Date: I: ' D-- <br /> R.E.H.S. Applicati n Approval: Date: <br /> EH 45 02 12-2-91 <br />