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A PAYMENT <br /> RECEIVED,, San o4quin County Public Health Servic-0 <br /> JUN 12 2002 Environmental Health Division L43 12- <br /> Medical Waste Management Program <br /> 6AN IN CUNTY <br /> PUBLICJOAQHEALUTH SERVICES <br /> 00NMENIAPPLICIA7­ 11ON 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 onditions 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 tile one of the following: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Information Document if the generator dr parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND,MAIL SIS P-NMENT <br /> ASIS <br /> V <br /> r <br /> T <br /> San Joaquin County Public Health Services Fla',:PAf M ENT <br /> T <br /> Environmental Health Division MAY 3 1 <br /> Wm <br /> E I.y <br /> Medical Waste Management Program -'S me <br /> Kl <br /> VIC <br /> 304 E Weber Ave VICKIE HER e Wey <br /> INITIALS <br /> Stockton, CA 95202 PH#8-455- <br /> Medical Waste Hauler Information <br /> (2 New 0 Renewal <br /> Medical Office/Business Name:. KajEpr Rarmamant- <br /> Medical Office/Business Address: S-bool <br /> City: Stnf-Vi-nn .State: <br /> Zip Code: c)5 2 1 a <br /> Contact Person: Ivinnif-A G -ay —Phone r4r: a:Z 6--)A 14 <br /> Storage Facility Name: KajSQr Pc­rmnnnn+-� <br /> Storage Facility Address: 7373 wes:L i-ane State: Zip Code. <br /> City: S f-nr-k 11-- <br /> Permitted Treatment Facility Name: Ka-; E:.pr Pgmrm;:inan+-_n <br /> Permitted Treatment Facility Address: 7-1-7-1 W--4- Lane <br /> City:-- S1--QCk+-Qn State: C& Zip Code: 25210 <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> I- Name: se- a+ i-achled I ist Title: <br /> 2-- Name: Title: <br /> 3- Name: Titre: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition, all copies of medical%.M2"_�rds shall be kept an file at generator's or health care protomionafs facility. <br /> Applicapt ature.• <br /> Title: V _Date:.�•,L <br /> elow This Line <br /> 02 —A v(2.9,- 5-32-b Do Not Write 8 <br /> IR-E.H.S. Application Approva (L4_z4_, Date: iration Date: <br /> EH4502 10-03-96 Date Paid 12- /01- Cad(h o(�5� 46 (circle) ACG <br />