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JUL-24-00 MON 12 11 PM FAX NO. P. 02 <br /> 11r1l412u14b 11;47 2090 33 FIFTH FLOOR PAGE 02 <br /> 67/1a/�60b E79:35 2094663433 FIFTH I-LOOR PAGE 02 <br /> Sarl Joaquin County PUbliC Health SeNiCQs <br /> Prlvirwirnental HeM 171vision <br /> Medical Waste Management Program <br /> APPLICATION 5CR A LIMITED QUANTITY HAULING EXEMPTION <br /> I o quari y fora"Limited quanlrty Hauling Exernptton" pursuant to tbc'Medical Wastn MaWoment Act" ilrrwing <br /> =ditions must be mat: <br /> The t�snerazar ar health care pro:ewilon-A generates IC"o than 20 pouf of rnedkal waw pot week, Msparts less <br /> t1 zn 20 pounds of medk2l waste 2t arty one ',lytta. rrraintains a trac;drzg daaument pursuant to Chapter 13, and the <br /> genoralor ar parent organ¢,16en has on file ane of the rbdowing: <br /> 1- A4edicaf blasts Marsgtc rnen.Prin if the nt0Vrlizal7t'In i9 a Nrgegmnbly genets ora smell <br /> quAii Sty gellerator+wife^to register pi=211t tc Chapter 4. <br /> U, <br /> 2. hiforr'rtatiorr Document it the generstor or parent cPj:Anewtiart is a small quandty gonorat>ar irt3d;tt7 <br /> regi�gw pursuant to Chapter 4. 4-t <br /> PLEASE COMFLF.TS THZ;NF0RMAA11CN BELOW AND MAtL Wrm $67 Foq5 TO; <br /> $;an Joaquin County Publ9c Health services <br /> 5r;virannlel tel Health Divisieri <br /> Medical Waate Management Prcgrarm � =, <br /> 304 E Weber Avie� � <br /> 5tocirtcan', CA 95202 <br /> lSlledlcal Waste Hauler InferR�atlun <br /> CT Hrrw C,d�Rcnew�t <br /> 5 <br /> medical Offiae/Eiuwinat-e Namr�: ,' ,1, f <br /> Mecical dffsce/Susiness Addra5s- <br /> City. ,S l•n r. k __ SL�ft=. P code. <br /> Contact Pelson;®�o� ��v�a�:� Phone <br /> stcrt�ge Facility Norn w-., \J <br /> Storage f-'aoility Addy �4 � �, L Com,_ ® <br /> city. A��t t "� 9tr�tc: A <br /> Permitted Treatment Fadiiiy <br /> Pomziti-4 Teeatment Facilgy Addrws 1: T� Cade: <br /> City: ...- -..___.. 1;� �c Stake: p <br /> ` Lk,t all employ erg names atld title,auftriz--d to transport t2ttr rned cal waste. If net,enough s apzm attach mfarrrr4on. <br /> i, Namr:-L-a �. ._w Title: <br /> abh;E VAp, Cteu vE. e.rN <br /> A'C*py of this exontp4on and a tta0krn5 dac=ant sl+all Oa in tuWptayeda pd=66siorr WIR Imes whet;nrttpo uIg madw ante. In <br /> g-4,1194r; all copies a!M94CA6 mcwd5- D w kevt on fila*t ap/1e ?% or wraith matt pt f*ssianars wetly. <br /> r n <br /> fpP1'L—'nt5i�nature. t"•- <br /> 1'itlr:�1�,Q„.d�i.S� <br /> �) Oo Not WriTe gelrnk This Lints <br /> RA.H.S.Appilcmion Appiovair,. Mate / f0 ir�tion D Jl Jam/ 1 <br /> g}1a;t<2 1"1-96 Date.Paid h Ot'Check���_(dfC1 ACLt <br />