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u.L uo/Zuul Lb:d l 2@ 946834_33 FIFTH FLOOR PAGE 02 <br /> i San Joaquin County Public He2ldw.rvicss <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APFLICA T ION FOR A LIMITED QUANTITY HAULING EXF-MpTION <br /> :-uzn„y :Ha,.,Iinq Cxerr tics" Our�Uant to the "?medical <br /> s -est ce rra� P Waste Management Ac."', the iizllowing <br /> --a ,e7,e-za:r c-^aaith :are c^r;essienal cenerates !ess than 20 pounds of medical waste per week, trarrsports fess <br /> %-a.- ::0 ;ce;'%!s -eC,c i waste a: any er,e tme, maintains 3 tracking document pursuant to Chapter 6, and the <br /> ;nrera;cr c care.: orgariza:icn "as or. 5ke one of the folicwir,g: <br /> Uara;e,r rert Plan if the generator or parent orga„ization is a large quantity generatcror a small <br /> Civ �; yeneratcr , wire. to register pursuant to Chapter d. <br /> �e generator cr parent organization is a small gtjW*ty generator not required to <br /> r^y vt°r pU�'Jani t0 �.`T3C:?r •t, <br /> '-ZASECO".tP'_�i e H :NFCR14A i(CN 3SI..OW 4 ND MAIL WITF? S67 a~EE 70; <br /> Public F'eaith Services <br /> :r�lr�nr en*Ai -4ealth Civision <br /> `:Iedical V'''ase Manocemert Program <br /> ZQG E ',Aleber .eve <br /> S,ockcton, CA 95202 <br /> K New G Rene'./al Medicam <br /> ( Waste Hauier Information <br /> Medical Office/Business Narra: (� p <br /> Medical fnce/6usiness Adcress: <br /> Cibl: State: Zp Cade: <br /> Contact Pelson: 11 (�(\ *� Phone T: / <br /> Storage Facility Name: <br /> Storage Facility A¢dress:_�� <br /> City: �. _ a <br /> State- ZJp Code: <br /> Permitted Treatment Fac:fity Name._ <br /> Permitted rea ent ra ,,/ address: D <br /> City:_ l a Sate: —Zip Code- <br /> list <br /> ode-!ist all employee names and Itles 3uthorzed to tra ispert the me6cal waste. If not enough space, arch information. <br /> 1- Name: 6. "e: M <br /> 2- ,'Name: _"e; .-4 <br /> 3- Name: i Wild Tile: <br /> `�W/�7 L5k IA,' <br /> A copy of this exemption and a tracking dccrunent shail ho in employee's possession at 311 times whaale p"arrspomc m&dfpJ waste. In <br /> addition, all copies of medical w:wa records sf+aii be kept on file at generators or hes:th =xm prctmskmarz facility. <br /> Applicant Signature: <br /> Title: Date: I I <br /> Do .Nor Write 3elow T his Lire <br /> R.E.H.S. Appll:=ion, Appraval: QGte:_/ .23/Q/ t xpiration Date: a( I <br /> EH4502 ,"3-96 Dare Paid / /9 10Z Cas; or a,eck T�(circle) Acct <br />