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SAN dkQUIN COUNTY PUBLIC HEALT VICES <br /> vTNVIRONhEENTAL HEALTH DIVES <br /> MEDICAL WASTE TRACKNG DO .NT <br /> (To be used with the'Limited Qua=tY HauLmg Ex=pdon'only) <br /> Medical Office/Business Name: QL A I' r,4- C, <br /> Medical Office/Business Address: Iteof <br /> City S f-o k-b n State: p Coder <br /> Phone Number: 4(o 3 g Gorrtact Person: :r- W+ C,JC- <br /> Name of Person Hauling Medical Waste: L d r k-1&C ; (Z.k; W" I �w <br /> (Must be person authorized on 'Limited Quantity Haulin emption' applicatio <br /> Quantity of Medical Waste Hauled: e i Date Hauled: <br /> (Not to exceed 20 pounds/week) <br /> Type of Medical Waste Hauled* �, t1 .r e s <br /> Permitted Treatment Fac" Name: .sn r C-n vircn— Permit # z- <br /> .vv�,�_v�,-iu.Q <br /> Permitted Treatme Facility Address: 4q!1 N 54-. <br /> City: r. State: Zip Code: ci�o/ <br /> Datedical Waste Received: <br /> S' nature of Authorized Treatment Facility Representative: <br /> X Tide: Date: <br /> FILL . OUT INFORMATION BELOW ONLY IF MEDICAL WASTE IS NOT BEING <br /> TRANSPORTED DIRECTLY TO A TREATMENT FACILITY [Le., Medical Waste is being <br /> transported to (1.) a permitted storage facility or(2-) a veterinarian or a home healtuh care nurse is hauling <br /> medical waste back to own facility.] <br /> Storage Facility Name:Sen1 T© ��_,��P�.���,bl�, 1- , IQ,5c�rurc 'ermit #: /L) ,4 <br /> Storage Facility Address: Ito D I <br /> City: 3:i-=c -4-b ,n State: e6 -21p Coder 1-2-10 <br /> Date Medical Waste Received: <br /> Signature of Authorized Storage Facility Representative: <br /> X Title:Ml-fltjate: -- <br /> HAULER SHALL KEEP A COMPLETED COPY OF THIS DOCUMENT ON %tLFOR 3 R <br /> F—Ti 45 03 12-2-91 <br />