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R8;'30 010 12:49 20993`L, 1 SUSD HEALTH SF 'TOES PAGE 03404
<br /> - /1s?J2A�6 ],3:46
<br /> 2- 061 sII&>� IALiI� cEs w+AuIz.
<br /> SAN JOAQUTN 0UNTY � I '� C�
<br /> C
<br /> ENVIRONMENTAL H1 ALT74 UFPARTKENT
<br /> $00 East T44in Strcwt,Stockton, CA,95202. 029
<br /> (209)468.5420,rax.,(209)46P-3433 Web:www.rjgov_orp/ehd , ,1
<br /> APPLICATION TION,FOR A UM.lirf ED+QU?INTM 9AMING EXEMP IO
<br /> C%/
<br /> To qualify!bra",i�lmi,ted.Quantity Mauling Exemption"pursuant to the""Medicat Waste Managgro,cnt at"I the �rri
<br /> conditions must bG m®t,-
<br /> The generator or bealth care professiorAJ gcneratsa less than 20 porj.nclq of inedical wmU per waok,trawport lass
<br /> tho,n 20 pounds of medical waste at*Ty otra time,mainteiits a,tracking Ocument pursuant to Chapter 6 and the
<br /> generator or parent 0rgani7ati0m,has on
<br /> file onG of the foitowlag:
<br /> l. mce t al, Waste akfa'"agemvif Plan i,f;the generator or parent organization is$large quantity generAtbt
<br /> or a.small gtIntlty gmntM,tor required to reg4", pursumt to Chapter b,
<br /> 2. InOrmatfon DocUmanf if the gen"ur ar parent Organization is a small quaritir�r generat;At nQt l equirad
<br /> to rV ster pursuant to Chapter 4,
<br /> <'? :ss ca pt4ta tic ir,-t'UM01fl "8eirrw 8a,'x-xsil with$77,00 foe to: I 11915- J� Q�
<br /> San Jeagrttn County J nylronmQntal kTeattlj ► t:artrnert /
<br /> Modlcal Waste MailaPovnant Program ��B'(� D�oz� F , YIVi L iii i
<br /> 6.00 East MAin 5freet, Stockton,CA 95202.3 L'�9 Y - RECEIVED
<br /> Med isod 3119 tler n do SEF' 1 5 2010
<br /> New Q Renewal
<br /> SAN JOAG3UiN COUNTY
<br /> ENVIRONMENTAL
<br /> Medicala,ruel . r � - .c HEALTH DEPARTMENT
<br /> r , j
<br /> l
<br /> Medical Office/Blislneg1 Addrese:
<br /> a
<br /> Corf'tact Person: � Citlr Stat�O � 7,jp Code
<br /> "."
<br /> Phone Number,
<br /> Stol,Rge)Fa.jt1j1 y Nqme: 41-
<br /> �.
<br /> S't6mge Facility Address; J r� 2 J•h� "�r*�GYJi. r" ,
<br /> cry state lip Carlo
<br /> def-Mitt+ed'T'reat�l g"t.V&C1]ity Ng me.,ft
<br /> Permitted TtOatment Faculty Andress:
<br /> ...- ca ,_ C � 7at
<br /> aSty Scale Zip Code
<br /> Last all ernpinyee r,amas and (1111 authorized to,tranaporttltc medical waste(I.:Fmc.re than 3,attach in
<br /> 2.Nome- _ ritle,
<br /> 3.1Yamec Title:
<br /> Title:
<br /> A eI Df tlI egempt:gn end A traekhm ductime"t ghall he+n e'hnpl r'a p61:1envion at all times.M
<br /> AediOnq,an oopioa of medkal wn®te
<br /> necerda shell lac ket:t nen rle A t hale tree,,+hvrtin,G medicrtl ivsatrr, in
<br /> APPlicen,t Signsitare: �OdCrAtOr+s nr hchlth Cpre prnfiviouara fiiniliEj+,
<br /> T itic:
<br /> .tav NOT W)KTV BELL W
<br /> R.F-AKS,ApAlication Approys.l.�SL� _ T S L 1 JV,IC
<br /> Cz�Air�rtiCrr!dates 12 o
<br /> Mata PbAtc: f /S//D
<br /> rrHnee.At �� aid:
<br /> i rn9rDr, 1,f sok Reserved r3y,
<br />
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