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JAESC HEALTH Fax 2093317067 Jul 11 2014 03:13pm P002/003 <br /> rUc. LV. LVI't J. II 'v VGII tiUCLgU II VvdII .) <br /> r <br /> RECEI Nr <br /> SAN JOAQUIN COUNTY JAN <br /> F—wrRONmENTAL HEALTH REPAPTMENT SaN e <br /> 1968);ase Raztlton Avenue,Stockton,CA 95205-6232 H '�ONM , <br /> •,r:.�„ ,r:;._.� : .. <br /> P/W1-OMU6�N1y <br /> retePhone (209')s 468_3420 4,r (209)468-3433 Wab: —.s; ov. r$ d <br /> APPLIcATIoN FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fora-Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Managem6rt Act'.the follo%via <br /> conditions must be,mct: <br /> The generator or health care p:ofcssioual generates less d=20 pounds of medical Waste per week,tcvzposi less <br /> thin 20 pounds of'medical waste at any one time,ml intains a tracking documeat pursuara to Chapter 6 and the <br /> .generator or parent organlzaticia has on file on®of the following-, <br /> 1, madreal WeisteManagemem Fran if the generator or ptut:nt ocg;vniaatiop is a large quanlity gencralot <br /> or a small qunatity generatorrequired to rcyister pursuant Io Chapter 4. <br /> 2. Injamia(ion Documrcnl if the guieraEor or parent organization is a small quantity gcntaLi6r not rt(tuired <br /> to registerlptusuani to Chapmr4. <br /> Ptcatxc coml)lctc the inforrnetion below and wzifl with S71.00 fcc to: <br /> Stat Joaquin.County Environinental Healll Departirn;nt <br /> Medical Wasie Managewcnt program <br /> 1869 E.RazeltolaAv6ue,Stockton CA 95205-6232 � <br /> medic4l W25te Hauler Information <br /> 0 New M Renewal AM <br /> !o9(erllcatl OfficeBusiness Name: � chool District/Health Sasvices <br /> Medical Off teBu5iaess Addtess: 1.305 D, V iuc Street; <br /> Lodi CA 95240 <br /> Ciry State Zip Code <br /> Contact Person: Susan Atkinson, ,Admin_ Secty. <br /> Phone Number: 209-331-7075 <br /> Storage Facility Name: C1eagarbore <br /> Storage Eacil:ityAddress: 7850 South R-A._ 13ridgefo'rd 'St. <br /> Srocictou CA 95206 <br /> Ciry Statc zip Code <br /> Pertnitte'd Treatment Facility Dame: save as above <br /> Permitted Treatment>raciliry Address: <br /> C;ty Stato Zip Cc?dc <br /> List x11 employee awes and titles outhorized to transport the medical waste(IPmare tbon 3,attach info): <br /> l_Alo.me: see attar-bed 11s Title: see at:te-coed list <br /> 2,Name; Tide: <br /> 3-14.8me: Titls: <br /> A copy or lhla exon9pllon ptnd a rt•* t a$ad be In rraployec's poscerrioa At A Rttues WLi1e trnurportaaC mrdteal WA3,17. to <br /> addlti4o,Hp Cnptez df niRd Na(t^Jtcordt sht9lt be c ort'Ile at gegrrvor's or hcKlrh care peort'lslontd's CaclWy.. <br /> Applicant Signature. Date: <br /> Title: 02or4lnacor,Special Seryi,eerJliealth <br /> DO NOT WR TE BELOW THIS LINE <br /> R.E.H.S, Application Approval: -- l X pate: C)�J'G2/l_ <br /> ERpizr16ol%note:jjn_� 3j l !A 1)atC PuiJ: I_ Z ! T Cxsh or Che.:A tr_1�34g1 17cx e(V�c1 13.v: � <br /> EHD 45•ut <br /> 1I MAW <br /> Received Time Jul, 11. 2014 3: 08PM No. 6568 <br />