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20 475 8356 aseracare0 57 p.m. 06-01-2009 212 <br /> 04/17/2007 04:25 9257980 PAGE 02/02 <br /> U4/13/2009 11:48 2094134@138 LNViRUNmtr-4 i AL mtAL I n <br /> SATs JOAQUIN COUNTY <br /> ENVIRONMENTALHE4kLTH DEPARTMENT <br /> 600 Bast t Bing StDckto,CA 95202-3029 a tl;vg <br /> tdLoha ffl (209)468.3420 Faso°( )460-341S Web- -SJ90v.0tg/0bd <br /> APPLICATION FOR A 1IMTED QUAMUTY HAMING EXE ON <br /> To qualit3t for a`ALL=ted Qumydty Hauling-Sxtslr0oe' to the"Medical Waste MMUSMcnt Ad',the following <br /> conditions n WA be met: <br /> The genmvZr or Imelth care prof=io nal SMemtcs 10CS thm 20 Pcua&of medical Waite ger week,tt^ansport less <br /> then 20 pounds of vmdical wa M at NW one tile,MintainS a ft0ang docu=nt perosuent to Chapm 6 and tote <br /> gencraw or parent orptil=ton hu on file One dithe 11 ' g: <br /> 1. �tdicat c ante /.a°nagatent Plant if the generator or t orgaiizWon.is a 1argc generator <br /> or a s=11 quantity Swerator req&ad to register pursv=to Chapter 4. <br /> 2. A?x ormadcm Documad if the generator or p4reW organization is a mralt quantity gencmwr not required <br /> to regista pu mint to Chopber 4. <br /> Please C"Ide W hdvwflon below and mail wRk S77.00 fee to: <br /> San,3'oKWn CMmty RAviM=cntd1 Health DRWftncnt <br /> MG&Od.wastemamment7rogmin <br /> 600 Just Main Suet,3toakton,CA 95202.3029 <br /> DIedical Wlsste ler Information <br /> Q New Renewal <br /> MledlW Offke/Business Naa tc. <br /> NladicalOfficeBusiurAess S: <br /> ssta Zip Code <br /> contact Demon: Wit <br /> Phone Number: <br /> Stonge Fasdif y N <br /> StMagc Facility A <br /> City Zo Coda <br /> Permitted Tmtvievt Fadlity t' RM: L <br /> J?mmiiftd Treatment Facility Address: <br /> ON <br /> Q31 Zip Code <br /> List all employee names and titles m9borked to transport the medioal wash(If OM atilt 3,wuh info): <br /> I.Namae: 1 Title: .� <br /> 2.Name: Title: <br /> 3.Name: Title: <br /> A copy of*b MOMPtion and 'ngd�AMem an be In employees POSSMION at An guile tmm"rting medical wade, In <br /> addition,a0 Orin oPnWt AvMra Shan kept eta ele at or'a or healm eater Al's fatibfty. <br /> Appli Signator®: Date: <br /> Title: <br /> DO NOT WRJTZ W TUIS Llr4E <br /> R. .kJt.s.Ap licadvtt val: Qn - ._.. Date: ,al of <br /> pati !UI l tate psid:�2 l 2 3 / _ b x#: D b3`i k 8 R=ci B <br /> ftm se n <br />