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03-25-'10 07;54 FROM- T-036 P0002/0012 F-073 <br /> SAN JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Cast Main Street,Stockton,CA 95202-3029 <br /> \ a ' I-Vi Pune.k/-Uy)k06-34zu("tr.A.`Lu%/vuo-j%xv rreu.%VWVV.sjgvv.V1WU1tU <br /> 101jf�So <br /> APPLIC NI'IO1V FORALIMITED QUANTITY HAULING EXER"' RNIOT NGALT11 <br /> MJ t1 t ' <br /> To qualify fora"Limited Quantity Hauling L�Xentpti011"pursuant to the"Medical Waste Management Act"/to�ll�e fo�,g� jug <br /> conditions must bemc ; <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transport less <br /> than 20 pounds medical wasie�at any one time.maintains a tracking document pursuant to Chapter'6 and the <br /> 1r,V11C VA UK;"Allu"121A. <br /> 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br /> or a small quantity generator required to register pursuant to Chapter 4. <br /> 2. If fot-mollon Document if the generator or parent organization is a shall quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> AM VILA AAO..4.1...Yr A a L t: aA at to a..4_.a_ a la a v E Jilin `6!LAA <br /> New p Renewal <br /> Medical Office/Business Nante: I e 5ti 0 i` <br /> Medical Office/Business Address: d lACr ='t -VK <br /> c,7 <br /> City State Zip Cod <br /> Contact Person: -A D 2,i (96V_ t l ' <br /> Phone Number: W9 elicito o . 12(11_040- t,11t-U'1v(�, <br /> S(ulla��atcitity Natetea;: . ' " <br /> Storage Facility Address: 7 1 I"3 1t11 QN) <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: 7465 U. 5,W)ff AsvV---. <br /> City State Zip Cotte <br /> t.tee e11 rueiAuyer narnri anti Belo,nutlius�iital lu Unuaputt tr`e mudi.-al waale orstttne t6eeu J.altars!iu('u). <br /> 1.Nanle: yl�='ice iVZC r`! Title: TllW 'jj;':e <br /> 2.Name: {' ' Title: y <br /> 3.Name: Wll, tf , IGL� 'Title: '& <br /> A copy of this exelnptlon'and a tracking docs n ent shall be in employee's possession at all tines white transporting medical waste, to <br /> adrtiHnel all onnloe of tnotlioal«w to rrenrilsitlisdi he honrt net file at venerstar.q nr health care nrafendow is aOWN._ <br /> Applicant Signature; �l c%{'�i DaW. <br /> Title: iJ1 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date:h / /-L-0 <br /> Expiration Date: 1)ate Paid: '3 1 Cash rCheck tl•� Received By: <br /> L'1iD05.01 V77e 0 � <br /> Ill <br /> 19,08 <br />