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vvu11LI IVo. Nish N. 1 <br />GA <br />r "Ro <br />G00 Eat Marin uota Oo 91ocktvn, CA 95207-3029 <br />Td'T4mhr (209) 468-3420 �mcc (?.09) 46$�3d331qF,eb., Ww,ejgov.orgl0jjd <br />,�q /I A.1 TLICATTON FOR A T, '',gyp QtA�NT�'a''X' �I,�I NIU 1' 7 1 e- TI ►N' <br />ooa (tiduv rrnlst be united Qttsu tY eulintgmot..ER�ittptiort"pat� ant to <br />Cizo "'TV(ad{ra1 VVa4te Ace*,, ,th,fvllowing <br />Talc zaremw or health MMpmfessiolnal saaamm lose than 20 pounds of medical veastt, <br />9atualtato�r ararC 2-0 nds nr�� �� at � rna[ e �titc, mA�ins a txarkir�g dvcumcgt pursrzatrf tU Che gCkug�art lis <br />P� nizatafott hgP an fiome of the following, mid the <br />11 medical lifar�rtr 1kt'anw�e�a�sr'P� iftho gen I= or or <br />ar s small qac+ icy en>✓tat�Or paz t t orgaPtor iotl a l�itgv �uatztrty ucl�itox <br />mq�al TD register to C'�la�ber q�, <br />2, ITtfor!?1Ah'on nnc�< int i tjtg gr.,�erator or Parvnt organiz ion amat1 quantity Bahct�ctar not <br />tp r�c&ter plMuagt to Chapter 4. <br />'PreM0 corelplete the informASOA below and mail with $77.00 fie to; <br />SMI Joaquin Covpry EMAMnmctttal Health Ikpaztmcnt <br />Medical Waote Mawgcmcnt ptugm u <br />600 02sC.A 9n Street; Stockton, CA 95 ,02-3028 <br />cdioa to �tticr T ow"m�i�o <br />O New x .Rezaewnl <br />WdCttll Oficefflrz;dpess NameA <br />Modied 4 oe�3usine�� A,ddre p; <br />SMLQ—aq-UW-_CXI?txblqHel ervicea <br />6a Ea.st _ Ron Ave <br />CotatW per9orr; <br />ChY 9,5,205 <br />Stsdm Zip Codi <br />]4'hRrzoNizmher: <br />V*ki,LWiI irn <br />8-8018 <br />Storage FACility NRlo C;San <br />Stow ftcility Addre,�,9: <br />r. o n County Pyblic kIs81 <br />60 zciton <br />._.. <br />C.1 <br />� <br />FertWDtted TteA.%clt�at:ilityName, <br />zfp952c <br />t � � <br />�'a�ttat�j'�`m=eat, Facility Address.I <br />4135 W. Swi R Ave <br />City J stat, Zip Cede""` <br />U.'t All Gmployce names and titles authorized to t raospott ito rMO&=1 wastemore <br />I . Name: Sea attached t 3, attach ua{`a): <br />2. Name: xxla: <br />3, Name: <br />"ltle; <br />A copy Of thk exemption 9nd q trQcking doaurnent shaq be in employaw s possaftlon at 911 brae® WWI* w4We. !n <br />transt+orlrng te+AdfC�l <br />addrtron, OU Copied Of mRtlital wmetA ngCgrsg Sh It be k00tt�On M0 tt ge!neratuen or health care 11ptofessloml x, tact ft. <br />Applicant Signature:--�Y...b 1� aN <br />Do Not Write Below This Line <br />R.E.H.S. Application Approval: �`�1.� Date: `� i <br />EHa502 14w; g6 08tPaid#--_ <br />— ---k'iration Date: 2! '/ <br />6 <br />L.� Cash or Uteck # _ (circle) Acc <br />