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,0N30/98 14:51 F.AX 0003 <br /> P 3 <br /> 9-30-1998 1 :52PM FROM <br /> San Joaquin County/ Public Heart Services <br /> Environmentai Health Derision COP <br /> Medical V4aste Management Program <br /> APPLICATION FOR A UrAITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quarry Eiaurutg Exemption"Pusuant to the"Medical Waste Management Aa'.the folfowing <br /> Conditions must be met: <br /> The generator or haaith care Professionl geneaates less than 20 pamds of rdedxal waste per week transports less <br /> than 20 pounds of medicsd waste at any one time. Trak tains a tracking document pussrsOnt to Chapter 6, and the <br /> generator or patent organization has an fie one of the falkwWg: <br /> t- MgdICal Waste Management Plan if tale generator or patent organization is a large quantity generator or a small <br /> quantity gerwaW required to register pursuant to Chapter 4- <br /> 2- information ocmmment if the generator or pawl organization is a sm2d gum* gensrator not required to <br /> register pursuant<n Chapter A. <br /> PLEASE CQMPLETE THE INFORigIAroN t3ELOW AND MAIL WITH S67 r-EE Tot <br /> San Joaquin Colony Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 96202 <br /> Medical Waste Hauier Information <br /> ❑ Now E Renewal <br /> Medical pf{ice(Business NWM IHS Horne Care <br /> Medical Offrce/Businesw Address: 2453 Grand Canal B1vd <br /> State: CA _IIp Cady 91,707 <br /> City: Stockton <br /> Contact Person: ¢ <br /> , Pstri Martin-9eue/Jenn er Will,gmH,_-_,_ Phones#: 957-7100 <br /> Storage Fac7ity Nanta: IHS Home Care <br /> Storage FacTi dy Address: 2453 Grand Canal Blvd Ste 9 <br /> cihj Stockton -Pp Stag c...�—: Codes 95 07 <br /> Permitted Treatment FacWty Nam BFI Medical Waste SjEste <br /> permitted Treat=*Fap'iiiy Addy - 4135 W Swift -- <br /> y_ Fresno State: Q Code: <br /> List ati employee names and toles authorized to transport the rnedxW waste. if not enough space, attacts lnforrr:atien. <br /> S- Natrle: See Attached List : <br /> 2- Name: Tile: <br /> 3• Nam- Title: <br /> A Copy of this axoModen and:tt:ddne doaaoarre shill o.irr a,wpieyes's Does stun at air& Vl*&Uxnepanbn atadted wasm- in <br /> adcOftM air eoples at madlog vuasre tlr.OeefS will be kept an We at 9wm*ftra (w 1100th care hr's tadft' <br /> ' <br /> Applicant Signature: Ykl s t''- <br /> Title: tr tt.2� `L�f�7Y7GCa1d Oaf <br /> Qa Not Write Selvw"chis Line <br /> ate: )/ tapttadon Clue: r, r l <br /> tL>=HS.Application App � D -7� <br /> EH4502 tams Date paid1 / / Quh or Check-I,--(circle) A= <br />