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OGT-08-99 03 :46 PM HEALTH CONNECTION HOME 9166311100 P.02 <br /> 10-07-T 999 4.45KI FRO fa.2 <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A UMITED QUANTITY HAUUNQ EXEMPrON <br /> o gualilY for a"UrvAed Quantity Houling I:xamptice puraumt to the"Medical Waste Marageffwt Acr. the tbttpwipq <br /> rendition roust be met: <br /> The ;eneretor or!oWth cora pral'amlonel generates 'ess Igen 20 pounds of rrwdcai mritn. per wo ok, ftwsports fess <br /> fan 20 pounds of medtcat waste at any ono time, mmntrana a tracking d=rrA nt au+suent to Chapter 8, and tt+e <br /> generator or parent organizadon has on Me one of the foilowhW <br /> MWCW Wbste Management plan if the gerw2lor or parent orgw*sdon;*a large quantity gwwratur or a(mall <br /> quertdty gerteraftr required to register pursuant to Chapter 4. <br /> Z. infW metlon Dacument it the generator or parent arpL*adoa is a erraA quantity generator not requkW :o <br /> rtgister pursuant to Chapter 4. <br /> PLI!AEE COMPLETE THE INFORMATION BL'LOW AND MAIL WITH $67 FEE T0: <br /> San .Joaquin County Public Health Setvion <br /> Environmental HOSMI Oivision <br /> Metrical Was.9 Management Program <br /> 304 E Weber AVG <br /> 5toclnon, CA 95202 <br /> Medical Waste Hauler Information <br /> New ❑ Renewal . <br /> ml edicel QftN6utin"s Name:• i �67,-,;W <br /> Medical Ot4tce/8usiness Address: <br /> city: 's,.rdC L' 41iftp Code: <br /> Contact PW"n: M- �r- Phone <br /> Storage F*dRy Name: <br /> Storage FV4ty Andress <br /> City: slstr: QA ao Codo: 7 <br /> fermttted Tremont FWity Rohit: <br /> P m7iCed Treat wt t=acM Address: <br /> Ctty. 3#atie _=Code: <br /> Lai all empbyte mamma and fuses 3uthaft*4 t0 ttenspart the medial wasOs. if not eMuGh 406M attach Inlbrrnadcn. <br /> • Name. 1 TEe: <br /> I- Name. %1" rdic <br /> 3- Name: TICe: <br /> A wW d aws examWen grid s be"V deewno t shall be fn*wVWT e'e pa mwkn staff on v@Qv Mar*rooftV ff*dW+Usabr. b <br /> Ad0Nrr. anavast d weds M�he We on ale st remauft r*so W"walwiwoft %cozy. <br /> Appiltant ign ro J <br /> Tide: dgGg: b <br /> Do Not Write Isiow rN3 Cine <br /> LE-H.S. Aoolieadon Aooroval: 0a1e! j L/a&piratiea gate: 1 1-D <br /> ID44W2 uuln to Cate Paid LAI 6 h or Cho&aI'f VR7-- _tcirdel A=_. <br /> I <br />