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12120/2010 10:40 2099337061 SUSD HEALTH SERVICES PAGE 02/03 <br /> SAN JOA QUIN COUNTY JENp <br /> ENVIRONMENTAL HEALT14 DEPARTMENT vk6 <br /> 600 East Main Street*StocktonP CA 95202-3029 ocr 2 9 20 <br /> Telepkane:(209)4694420.Fo=(209)468-3433 W.-b.-WwW.sjgQV-0rS/ehd -SAN 10 <br /> 40,4001V CO <br /> APPLICATION FOR A LIMITED QUAEFAIV/pd, U, <br /> NTITY HAULING EXEMTT16W7-H" <br /> ,CPA qt <br /> To qualify for a"Limited QUOnft Hauling F—terriptio7f'purse ant to the"Medical Waste Management Act".the following <br /> conditions must be mct.- <br /> 7be generator or health care professional geriemrai less than 20 pounds oFmadical waste per week,transport less <br /> than 20 pounds of medical waste 01 any one time,malnufris a Tracking document pursuant to Chapter 6 and the <br /> generator or Parent organization has on ffle one of the following: <br /> 1. Medical WOStd Manage neat 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. Itylarmaflon Docament if the generator or parent organization is a small quantity tfi*mPt'required <br /> to register pursuant to Chapter 4. <br /> ) <br /> Please complela the Information below and mail with$77.00 fee to; <br /> SZKI Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street,Stockton,CA 95202-3029 J° aiA <br /> �.9 <br /> MedW1 Waste <br /> —HRUIer <br /> Ej New 19 Renewal <br /> Medical Office/Busluess.Namez Stockton Unified School Diatrict <br /> Medical Office/Business Address: 701 X. Xadl,s'ou Street <br /> -$tockton CA 95202 <br /> Contact Person-, <br /> Cita' state Zip Co4a <br /> TAM X_vans-, Administrator <br /> Phone Number- 202,933.7060 <br /> Starage Iftefty Name-, StoQhQ2 UniEfad Mxealth Serviced Dept <br /> Storage Facility Address: 1144 E. Channel Street <br /> Stockton CA 95205 <br /> city Stato Zip Code <br /> Permitted TreatMent Faclifty jVstme.- 5rericycle Inc <br /> Permitted Treatrnent Facility Address, 4133 W. swift <br /> ftesno, CA 93722,, <br /> City Slate Zip code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,att=hinfb): <br /> I.Natne: See attachment Title: <br /> 2.Name: Title: <br /> 3.Name: Title- <br /> A-W ofthb exemption and it Irmeldng document Shalt be In,employee,3 p9mq0o"at all time$While tr1kn%polling MediCal waste. In <br /> Addition,all cOPI's Of mcdkO waste records shall be Imp*on file at Pnerator$s or health care Pr6ftnion2lps fibeilley. <br /> Applicant Sigilature: Date. 10/18/10 <br /> Title-, <br /> TI) <br /> )DO NOT WRITE BELOW THIS LINE '%, _n <br /> X-EX-5-Application Approval Date: <br /> Explmtfon Date: :Ch�ec k �Ll 9 4910�eSS-S-k <br /> J—ZALLa Paid: X 10�/7Z-AA /�Ifo, <br />