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04/17/2007 04:25 925798W <br /> PAGE 02/02 <br /> 154/13/2005 11:40 20944r8 LNViHUNMtN 1 4V- <br /> SAN rwuc Ali c l <br /> JOAQUIN COUNTYFIft" COPY" <br /> ���� <br /> L U, <br /> ENv)RoNmj,4NTA.t HEALTH DEPARTMENT <br /> 600 Fast Main Street,Sto�cjLtor,CA 95202-3029 <br /> Tdephomp..-(209)468.3420 Ffi:61(209)468.1411 Web:WWW,9j9QV,0r9/*bd <br /> APPLICATION FOR A LIMITED QUANTITY HAVLJNG EXEMMON <br /> To qualify for a"Limited Quantity Hauling-Axcmptioj�'ptirsuant to the*,Medical Wastc Matagement Act",the following <br /> conditions must be met, <br /> The generator or health care profmionalge-ramtes less than 20 pouzds of medical waste per week transport less <br /> tban 20 pounds of Tnedical wagto at any one time,maintains a trac)dng document Pursuant to Chapter 6 and the <br /> generator or parent organizOian has on file one of the following; <br /> 1. Modinal Waste ManaVmenf Plan if the generator oTpamnt organization,is a)a-rge quantity generator <br /> or a small quantity generator required to register purswmt to Chapter 4. <br /> 2, Informadort Zbcumenf if the generator or,pa=t organization is a=all quantity genewor not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: <br /> San,jonqidn County Envronmental Health Dep!Wment <br /> Medical.Waste Mazagmcrlt Program <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> e d i e e <br /> -Aj W <br /> New �Renewal <br /> N <br /> Medical Office/Business Name: <br /> Medical OfflcM3usiness Address: <br /> St eta Zip Code <br /> Contact Persom. <br /> Phone Number: <br /> Storage Facility Name. sCr�.Iljjs-�'. <br /> Starago Facility Address, <br /> City Riot& Zip Cc& <br /> Permitted Treatment Facility Name: ch uru)-' <br /> permitted Treatment Facility Address: --2115 P. A 12 5'\ <br /> \/L1ZN'4 ON <br /> City —I Zip Cade <br /> List all employee names and titles authorized to transport the medical waste(IfMorc tbari 3,mach info): <br /> 1,Name,. pt Title; <br /> 2,,-Name:krA e, —I I KI I I, Title, <br /> 3,Nam'c s6r,64- Title: <br /> A copy of this exemption Tandc inn be In employee's PoNveqsion sit AH JzmaN, ile transporting mrdical waste. In <br /> t' <br /> addition,all copies of medical e recortts shall bm kept on file at generator's or With euro prorvn;lonalls facm(y. <br /> #4 <br /> Applic Signature: Date" <br /> Title-, <br /> DO NOT WRITE BELOW THIS LINE <br /> &B.H.S.ApplicatiQrx Approval: —Date: -irjal-o <br /> Expiration Pate: I I,/ -./PO 'Date Paid; \2,/Z3 /0% Casb or Check#:JD634 U g RexcivedIRr.. <br /> CVM <br />