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01/16/2002 , 17:22 707967 S ST HELENA HEAL CEN PAGE 01/01 <br /> San .Joaquin County Public (health Services <br /> Fnvirortmental HesIth <br /> Pin m <br /> Medical waste ivManagme em <br /> APPLICATION FOR A LIMITED QLIANMTY HAULING vwpTtON <br /> To qu nY <br /> far a«t.1rYSit2d Quantity Fieugnq 6y,P[T;P606, pu suant te, the"Utedficat V+ ie Manati7eertant Ate', the bll4wing <br /> carlditl ns must be met <br /> rater or hsa9th care professignal generates less than 20 Rounds or rnsdiit waste Per w0ek,.lydnspai:s less <br /> The g e ste at an one circle, maintains a Incking doca hent pursuant to 0430W 6- and the <br /> than 2 pounds of me medical has ort fila one of the following. <br /> gen tar or parent Organization <br /> t_ MeQ�Weste,4ranagerri <br /> enc Plan if the generator or parent organrre'son is a lacy®quantity genemtxsr or a Mad <br /> gclantitY generator regrzlred to agister pursuant to Chapter 4. <br /> uty generator not required to <br /> ! formation D= Meni� if the generator or pssent organization is a s,natt quasi <br /> �- � , <br /> register pursuant to Chapter¢. <br /> t.ETE IMS INfORMA�OPi: <br /> P E COMF .88�.QVSr ANDN' tf»YV�TH S8T Ttl: <br /> San oaquin County Public Health Services <br /> Ea onmental Health Division <br /> Med cal Waste Managemerit Program <br /> 3Q4 Weber Ave <br /> Stoc ort, CA 95202 • <br /> Medi=al Waste Hauler information <br /> N 1 W�VVIA <br /> . <br /> Medi 14ffiCel6uslness Name:• �Q <br /> Medi I OfnceMusin®s$ Add aSs* State: ' gy p Code:_ -- <br /> j1oR8 <br /> City: <br /> Cori Ct Person: <br /> St. Helena Hos it <br /> Name: a1 <br /> Ston ge FZaIlty 650 S .nitar um Rd. <br /> Sto ge Facility Address: ear Park State: C. --�-- Code: 9�k5 <br /> City <br /> St. Helena Hospital <br /> Pe fitted Treatment Facility Name: same ass ove State: �p Code: <br /> Pe ltted Treatment Facility Address: <br /> City ation. <br /> net the ntediCai wast&. If not enough Space,attach inP�rrn <br /> List alt employee names and titles authorizyti to tra Heart at Hisk, Covrdinatoz <br /> Lisa Rellie, MA Title: <br /> •t- Name: Title: ducata�' <br /> Name: e sy I us, Title: Bea th uca or <br /> - aze ar er, <br /> 3- Nance: • rthV me+Simi waste.e. is <br /> A c pY of�g®xentpdon arca a backing documajit z1=4 be in OMPICY"'.s pssssassiaA ax pll tirrces anara <br /> rtia fa <br /> asfdee,alt s'Qx - =pedl !wa.-ta sea %boa be kept an fife at Seneriaae v e r heslth'ca m�f� <br /> ,gyp'tEant Signatu a Dater <br /> Tit.{ - <br /> Coox n geart at Ris <br /> Do Not Write Below This line <br /> Date_ <br /> L/02-Expiration <br /> P- FI.S. Application Approval: -circle)Cash or Chemo g�(circle) A ---- <br /> SQT 1Q.A3A6 Date Paid �•,,,._,�._— <br /> Z0 mid i 1000U Hl.:1IJ ECVE89060Z SZ:9Z Z®0ZIS T/L0 <br />