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3-06-203 1=21PM FRO#D DIV OF TRAINING 209 937,720 P.2 <br />ej,7rviol /-rjuD tu.4u ...... <br />San Joaquin County Public Health Services <br />Environmental Health Division <br />Medical VVastd Management Program <br />APPLICATION POFD A LIMITED QUANTITY HAULJNG EXEMPTION <br />To nuafify ror a %,im+ted Quantity Havfing irxaMption" pursuant to the "Medi=l Waste Management AC", the following <br />wnditions must be rrlet: <br />The generator or health care pro(essionat generates less than Za pounds of medical waste per week, transports less <br />than 20 pounds of medical waste at arty time tinse, maintair+s a i1acking document pursuant to Chapter S. and +he <br />generakir or parent organization has on File one of the following: <br />I- Mectical Waste Managertivat Plan if the generator or parent organization is a large quantity gon ator or a small <br />quantity generator required to register pursuant to Chapter 4. <br />Z- Informatiurf Document if the generator or parent organization is a small quantity generator not mquired to <br />register pursuant to Chapter 4, <br />PLEASE COMPLETE THE iNFORMATION BF -LOW AND MAIL WITH 557 F=E To.- <br />San <br />O.San Joaquin County Public Health Services <br />Environmental Health Division <br />Madical Waste Management Program <br />304 E Weber Ave <br />Stockton, CA 96202 <br />Medical Waste Hauler Information <br />New at Ftenewal <br />MedicalOfficeMusinessN3md: 6I4,fffi .�/•�CrIGTI✓ /�t/l � e'/Or- <br />Medical aWSusiness Address: <br />`r ,.__.�.-/'1✓• State: CA Zip Code: l S-O.;t_- <br />Contact mere naa. t!! / r- ---Phone _. w:, 413 % fr, l� <br />Storage Facility Narna:_e rA&�LAtZX96K <br />Storage Facility Addres$* 110 4-AeAAEA 3; r 7- <br />city:r•5 ,�00C:It9`Oiy - �Jp Cade: <br />P�- Jtted Tmatrtment Focilfty fame: F- ei r. Cl -x / C <br />Permitted Tmatment Fa lily Address: 7 i s 4--4c Ic <br />city:,�.� , ... —' d.,r g a ✓ oh w T, � slate: ,_..zip Codi: <br />: st all employee names and Goes auit+orizdd to transport the medical waste. It not estougri space, attach information. <br />I- Name: t � AI l Z �, `r S � ZMe rr�ltie: � +� <br />Z_ Na1mc�r rwcks t Title: <br />3- NamsTitle- <br />A Dopy of this exomaUa" and a tricking d4aum*"t stun b*,n ymptCYee'a 110"*SlrOn at ail tlmsa .moll* Itansporb'nq to dhZ4 waste. In <br />addldbl% 291 OdPISS of mLqlpal WmxtP to slush be kept an We at geNeratgrs or health case profossiomrs tacit:ty. <br />App0CAnt <br />Do Not Wr@tr 3eiow This Linc? <br />i <br />It,E.M.5, Rppfication Approval: Date: J62 / Expiration Date --IL/ / <br />EH4soz 104346 Date Paid ^•, ,I 13D! D 3_dsh to Check Acct l <br />