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FEB-18-00 FRI 02:10 PM FAX N0, P. 02 <br /> a—i 6"1LIIJW i i :I03AM Flint P.2 <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualifiy for a"Limited Quantity Hauling a xemption~pursuant to the"Metrical Vvas:s hAanagerttent AC;', the following <br /> candititlns must be rneL <br /> The generator or health Gare pmfesaiunal generates less than 20 pounds of medirai waste per week, utinsporC;Ins.; <br /> than 20 pounds of medical waste at any one time, maintains a trucking document;ursuarit to Chapter 6, and the <br /> generaror or parent orgunizntian has on gle one of the following: <br /> 1- Medical Waste Management Ptah if the generator or paront organizaaen Tv a targe quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4, <br /> 2- !nfarmation Document If the gener4tur or parent orpnization is a small quatWty generator not require-d to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATioN BELOW AND MAIL WtTH SST FtE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information �•�_____..-_ <br /> C] New 99 Ronewai tt� <br /> Medical OfficcVgusiness Narne:�T"/.I_l )-IM �Od t J-tVC . <br /> Medical Office/business Address LId12(I LaKC-.S UPt Uc. _ <br /> City. `-rDCK'VON._. Slam _ _C-A zipi`- <br /> Contu(A Person: IZATN L E I h'C;V C� Phones2UR _�j� Q <br /> Storage Facility Name: 1, _rt /NK Loo --r4VC. <br /> Storage Facility Address: t t `E�~ 117t—'--" _ <br /> C;fy:� ,�i OC.f:'175M Stats: CATip Code:��C) <br /> Permitted Treatrnent Facility Name: <br /> Permitted Tr-oatment Facility Addres,i. _ <br /> State: -p Code: -� <br /> Ust all employee names and titles authorized to transport ft medical was o.It not enough spaces attach information. <br /> 1- Name: jV-rm.EZ:AI f«uc61r=-t4'_ 'N.r✓ <br /> 2- N;:�ime: (_ y � �...� Title:_ <br /> 3- Name. t^L ni':A :3�)tUC- �:�— - -- _r rtie: r- <br /> 8-- IK 7-f<A bat N t+u_ t—V AJ I—VAI <br /> A copy o/Mia excrtrpftn and 7 VwJd Mx doeratr W%half bo in eeie 's *wian at all harp wfiita bOrvoofffrQ Medical waara. In <br /> WrtioN all ecplwae of mvdtcal vowAv rvcords shalt ba Inapt on ilk at gqnWzW5 or hearth can mof uiCelai's fatilay. <br /> Applicanlc Signatwrt:�� <br /> Title: ! <br /> 00 Not Write below This tine <br /> R.E.H_S.Application Approval: Date-,24L / C7Expirataon Date: <br /> iMssol 1043-% Dato Paid rj,2!-1(al ,`1 or Check tcircte) Acct _ _ <br />