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01/14/2003 14:19 70796757 AHNCN ACCOUNTING • PAGE 02/03 <br /> —ir' <br /> -- Say�,vaquEl� Cournty Public H alth <br /> Environmental Health GivisiOn <br /> Medical Waste Manageme It Program <br /> APPLICATION FOR A LIMITED QUANTI HAUI-ING EXEMPTION <br /> � <br /> ption" pursuant to th "Medical Waste Management Ac:', the fallowing <br /> To qualify for a"Limited Quantity Hauling Exem <br /> conditions must be met; <br /> unds of medical waste per week, tral'tspor�5 less <br /> The generator or health care professional generates less than 20 document pursuant to Chapter S, and the: <br /> than 2a pounds of medical waste at any one time, maintains a tracking <br /> generator or parent organization has on file one of the following: <br /> Medical Waste Managernent Plan if the generator ar parent organizadon is a targe quantity genet2tor or small <br /> 1_ I <br /> quantity generator required to register pursuant to Chapter4. <br /> lrPd to <br /> " r parent organ' tion is a small quantity generator not req - <br /> " Information Document if the generator v <br /> register pursuant to Chapter 4. <br /> PLEAS COMPLY INFORMATION BELOW AND MAIL tTH 67 Fr=E TO: <br /> San Joaquin County Public Health Services <br /> �A , <br /> -• ent Program <br /> nvironrnentai Health Division am �\ <br /> Medical Waste Managem <br /> 304 E Weber Ave <br /> _Stockton, CA 95202 <br /> medical Was HaUk r Information <br /> ❑ New i Renewal J ` <br /> i5 ea/ <br /> Medical Office/gusiness Name:. <br /> Medical Offic usiness Ad ss: Slate_ �Gt/M�p Cade: <br /> City: f' -r� Phone r. <br /> -Contact Person: <br /> -- ----storage Facility Name: r <br /> ystorage Facility ddress: Sia e: ZIp Coda: <br /> _city: e� <br /> • <br /> Permitted Treatment Facility Nam r Gi 5 <br /> -_.pemlitted Treatment F2ciiity Adc� ess: State: � �ap Cade: <br /> city: <br /> List all employee names and'tlttes authorized to transport the edical`nraste..if not enough space, attach I armatian. <br /> 1- Name: <br /> Title: R <br /> Title: �--- <br /> 2- Name: Title: LrlAOIF <br /> 3- Name: -��— <br /> /pft', s po wessivn at all dMes while tmnsporttng madC a1 wastia. In <br /> A copy of this ezemptlbn and a tracking document shaft be In employ essiaml+g f c1 ity, <br /> addition. alt 40piee ab'medlcal was shall bs ke n Fite at genraw" or health cera prof <br /> Applicant Signature. �- <br /> Title., <br /> �oar late• / / I �� <br /> Do Not Write Belav This Line <br /> U.H.S. Application Approval: <br /> Date---L / ._apiration Date: I i <br /> Date Paid / / Cash D (circle) Acct <br /> EH4502 10-Q3-96 � <br />