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PAYMEN-1 <br />RECEIVED <br />Saftiquin County Public Health Servat y� <br />Environmental Health Division ! OW511Z, <br />JUS 1 oo� Medical Waste Management Program <br />1 PUBLICO HEQAITH ERVICES <br />�COUNTY <br />I\ARHNMFN*RPLIGATiON FOR A LIMITED QUANTITY HAULING EXEMPTION <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the following <br />conditions must be met: <br />The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br />than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the <br />generator or parent organization has on file one of the following:_ <br />1- Medical Waste Management Plan if the generator or parent organization is a targe quantity generator or a small <br />quantity generator required to register pursuant to Chapter 4. <br />2- Information Oocument if the generator dr parent organization is a small quantity generator not required to <br />register pursuant to Chapter 4. <br />PLEASE COMPLETE THE INFORMAnON BELOW AN lL1 NCHM Fib's` iX81�NT <br />San Joaquin County Public Health Services <br />Environmental Health Division MAY 3 1 '%002 <br />Medical Waste Management Program�' <br />304 E Weber Ave ViCKIE HER a 31 "Ii <br />Stockton, CA 95202 INITIALS:�, <br />PH # 8.455-1 <br />Medical Waste Hauler Information <br />Q New G Renewal <br />Medical Office/Business Name:. K n i c- = r Po rm n n On t <br />Medical Office/Business Address: -T 93eguantar=c <br />City: Stockton State: r1A -­ p Cade: 9 , 21 n <br />Contact Person: Mnn i r a c,3 -ay _ _ _Phone n•, d 2 Fi -rid 4 4 <br />Storage Facility Name: K a; c r p arm a m en tr <br />Storage Facility Address: 232 3 bl e S t T. a n n <br />City: Stnrktnr State: r -a Zip Code: 9521 D <br />Permitted Treatment Facility Name: _K a e r Pcol --m n n n n t a <br />Permitted Treatment Faciiity Address: 7323 war t Lamp— <br />City: <br />. anPctty:S! n r k+ n n State: r• A Zip Code: 9 SL_ <br />List all employee names and titles authorized to hansport the medical waste. If not enough space. attach Information. <br />1- Name: 1 ict Title: <br />2-- Name: Title: <br />3- Name: Title: <br />A copy of this exemption and a tracking document shall be in empl 's possession at all times while transporting medical waste. in <br />addition. all copies of medicalrds shall be kept on file at eneatoes or health caro naps facility. <br />/ ,L <br />`02 -o <br />&-r- 53Z • Do Not Write Below This line <br />R.E.H.S. Application Appro Date: 2fxpiration Date: <br />EH4502 10-03-96 Date Pai �/ IL /oL ecic �J-i�%'4S (circle) ACCL <br />