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FROM FAX NO. O. <br /> 30 2003 04:34PM P2 <br /> Sari Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Urnited 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, transportm 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 ffle one of the ;allowing: <br /> 1- Medica!Waste Management Plan if the generator or parent organization is a large quantity geneiztor ora small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Information 00CUMent if the generator or parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLL ASE COMPLETE THE INFORMATION SELOW AND MAIL WITH $67 FZ TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New C3 Renewal <br /> Medical Office/Susiness Name.-. SAN JOAQUIN COMM IMALTH CARE SERVICES DZpAKTKm <br /> Medical OfficeJ8usiness Address- P. 0. 13ox 1499 <br /> City: French Lamp, State:7- U- p Cade: 95231 <br /> Contact Person: Chuck T—eek <br /> Phone <br /> (209)X66 <br /> Storage Facility Name:_ <br /> Storage Facility Address: <br /> City: p Code; <br /> 7er�m!;;d'Treatment Facility Namw- San Joaquin General Hospital <br /> Permitted Treatment Facility Address. 500 West tal Road <br /> City: Frerich.,Camp, CA zip Code. <br /> List all employee names and Wes authorized to Imnsport the medical waste. if not enough spam.' attach inkmmdoiL <br /> 1- Name:- Max Cervantes Title. Housekeeping Servic*e Warker <br /> 2- Name: .Tose L <br /> opez Title: <br /> 3- Name: Luis Ruante Title: <br /> A ropy Of"s OxgmPdOn and a tmeking doc=erit shad be in mpj*y**,3 p=ae=14n at M 11nm white bmrigporung medical waste, to <br /> addition, all copies of medig2ji shad he kept an file at generator's or health ones prafe"aWs <br /> Applicant Signature: t2� <br /> Title: Facilities mallaser <br /> Data: <br /> Do Not Write Below This Line <br /> 07. <br /> R-E.HS.Application Approval: 7 Date.- I piragotL n Da I <br /> CH4502 JG.W.96 Date Paid (:A3� or Check' ffil <br />