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R_ 5_ 98 THU 11:28 DELTA B D BANK STKN FAX N0. 20946202210 <br />P. 02 <br />P. 2 <br />Sen Joag61n 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 EXOMPO nr" pursuant to the "Medical Waste Management Acf, the following <br />conditions must be fret <br />The generator or health care professional generato less than 28 pounds of medical wasae per ween transports less <br />thart 20 pounds of medieat waata at any one time, maintains a traddng daument pumuant to Chapter 6, and the <br />generator or parent organa ion has on ft one of the following: <br />I- Medical lrlhsfe Menegenrent 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 it the generator or parent organization is a small quantity+ generator not required to <br />register pursuant to Chapter 4. <br />PRASE COMPLETE THE INFORMATION BELOW AND MAIL VM $67 FEE 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 (Coo" <br />© New)( Renewal Medical Waste Hauler Information <br />Medical OffkaGuslnessName: Delta Blood Bank <br />Medical OfftceMuMness Add�e�s: <br />City. Stncktnn8tat8: Code:_ 9.�z? <br />Contact Person:_ anan narker Phone# <br />storage Facility Name: <br />Storage FacrTdy Address: ti N _ f nmmQJ��a ��x�g� <br />C t n r it f- n n ' ,---I_■ �•"LI_"• <br />Cdy: -- -Mate: rip Code: q s ? n 7 <br />Permitted Tres kwt F8zRy Nuarte:_____ AFT Mad -a wa = i -a c;c ct j- P m e <br />/Permitted Treatment Facility Address .._. <br />A Zip //ffes�,, <br />Ust all employee names and 11W adtt ezed to hansport the medial waste. N not enough ug space, attach irrfonta3tion. <br />3- NaMe. See attached list Tft: <br />2- Name: Title: <br />3- Titlr <br />A Copy of this euanrpUM and a backing dorms d sialrl be in employoels Ppr**6iw st all tin vAft mzpavnq na orw waste. In <br />addltlon, arl Copies of nc s be knot on Me at omuratoft or bnnh mm pros ubmrs %cm. <br />Applicant Signatu _ 1 • --~ %� _ _ - <br />Do Not Write Below This Line <br />R.E.H.S. Application Approval: ate: 3 ,�S,FxPiratlon Oats Zi ! <br />u h4X2 IM3-M Date Paid ;- /Z5 t 9g Cash (Circle) Acct <br />