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oaquin County PublMealth ices <br />Environmental Healt7nivisio <br />Medical Waste Management Program <br />APPLICATION FOR A COMMON STORAGE FACILITY PERMli <br />A Common -Storage -Facility is'Litilized.for the collection of medicalwasteproduced by <br />small quantity- generators operating independently,"common" <br />but sharing- the <br />storage area. <br />PLEASE COMPLETE THE FOLLOWING AND MAIL WITH APPROPRIATE FEE (SEE BELOW FOR FEE CATEGORIESFJ 0: <br />San Joaquin County Public Health Services <br />Environmental Health Division <br />P.O. Box 388 <br />Stockton, CA 95201-0388 <br />-j <br />PERMIT MAY ONLY BE OBTAINED BY <br />ONE OF THE FOLLOWING (CHECK ONE): <br />0 HEALTH CARE PROVIDER <br />0 MEDICAL WASTE HAULER <br />PROPERTY OWNER <br />PROPERTY MANAGEMENT FIRM <br />COMMON STORAGE FACILITY FEE <br />CATEGORIES (CHECK ONE): <br />,&2-10 MEDICAL OFFICES= $134 <br />a 11-50 MEDICAL OFFICES = $265 <br />0 51+ MEDICAL OFFICES = $473 <br />Name of Permit Applicant:WofwA §(��e Phone <br />Address of Permit Ap IiT <br />C ant: 1412 life 64 / <br />City: = --e_ ?-e State: Zip Code: 9Y-ov <br />Contact Persomme,,,A�s 2 6'-f C', Title: Phone* P'6& <br />Common Storage Facility Address: J-60 N® 6AG66r_&LA <br />City: ±�M?C15rc-*j State: 64, —Zip Code: 0!j204 <br />PLEASE LIST BELOW THE NAMES OF THE OTHER SMALL QUANTITY <br />GENERATORS WHO WILL SHARE THE COMMON STORAGE FACILITY (IF MORE THAN <br />5 ATTACH INFO)- <br />1 1)Name: Address & Suite <br />2)Name: Address & Suite <br />3)Name: Address & Suite <br />4)Name: Address & Suite <br />)Name: Address & Suite <br />Applicant Signature: title: 'A 6,2-z Date: 7 -!L>ej <br />.4 z <br />N­— <br />R.E.H.S. Application Approval: —Date: <br />EH 45 01 09-27-95 <br />