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t 171/13/2002 11:55 4683841% PAGE 03 <br /> OP P_ 2 <br /> ,San Joaqulh County Public Health Services <br /> Environmental Health ,DiviSloh <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING ]EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medir,.al Waste Management A.cC', the for�wtng <br /> conditions must bo met: <br /> The gen6rator or health care professional generates less than 20 <br /> POUnds of than 2a0 pounds of medical waste at any one time. maintains ■ tradd g dump pursuant t Cha, ter s. Sr less <br /> he <br /> generator or parent organization has on fie one of the fallowing: iter&. and the <br /> �- M+sdlcsl Waste Management Plan It the generator or parent organization is a large quantity generator or a smolt <br /> quantity gonerator required to register pursuant to Chapter 4, <br /> 2- Irrformati'on Document If the generator or pint organIzation Is a orn.alr quantity <br /> reg pu nt to Chapter 4, q � generator not required to <br /> PLFASE COMPLETE THE 'NF04MATION BELOW AND MAIL WITH $07 FETE To; <br /> Sen Joaquin County Public Health Servi <br /> fts <br /> EnAronmentai Health Division <br /> Medical Waste Managemenj program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> b New q Renewal Me [Cal Waste Hauler Intbtmatlon <br /> Medical c)fliceA3usrn®ss Mame: d ` <br /> Medical nein a Add <br /> O 4L zrp code;- <br /> L il­ <br /> ftrage Facility Name: <br /> storage Facility Address:1111,11 <br /> c <br /> City-, c k—� <br /> State- L Ziq <br /> Pem9tted Treatment Facility Nam*: <br /> PermitWd Trfaatman Faculty Address: <br /> City. <br /> List all employee names and titles autholixed to transport the medlo;W waste.este. if not enough space, attach inFerrrlatlan. <br /> I- Mame- ,7a-( - J <br /> 2- Name. ac Title: <br /> 3- Name: 'Title: <br /> `flue: <br /> A*QW arthls ex®mption and a tracking document shall be in of meern *s { at dgl <br /> *dd$roe,ell poples dical M shall be kept on,016 r<i franc mQdrGAI wasio. !n <br /> gerienifors or houlth cafe sloml's facility. <br /> Applicant Signature: < <br /> Title. <br /> Date: <br /> Do Not Write below This line <br /> lt.E.H.S. Application Approval. Date�l <br /> El OM 100;o _qd Date Pai 24Q2 xpiration Date. .../ 1®, <br /> Gash or Check (circle) Acc <br />