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09/07/99 22:46 a 209 9574142 T IGUERO P.02 <br /> ES�75—1 9yy 1 Z. 1.qF m Fpcir-7 P, c <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program OOUA,,, <br /> APPLICATION FOR A i.IMITI±b QUANTITY HAULING EXEMPTION <br /> To qualify for a"Lltnited Quantity Hauling exemption" pumuant to the"Medical waste Management Act-, the wing <br /> conditions must t;e met: <br /> The generator or health carp professional generates less than 20 pounds of medical waste per ween wansports 1055 <br /> than 20 pounds of medical waste at any one tinct, iraintains a tracking document pursuant to Chapter 6, and the <br /> generator or parent organization has on fill: once of this following: <br /> Medical Waste Management Flan if th"generator or parent organration is a targe quantity generator or a small <br /> quantity generator required to register pursuant to Chapter a. <br /> 2- Infannedlon Docurnerit if Jit generator qr parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE 11iE INFORMATION UEL.OW AND MAIL VVI i'H $61 FEE TO: <br /> San Joaquin County Public Health Servic c% <br /> Environmental Hoalth Divi3ion <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 . <br /> Medical Waste Hautor Information- <br /> New Q Renewal / r <br /> Medical Office/Susfnnss Name: I <br /> Medical Office/t3us+ ess Address:4L 2j�" <br /> City: } r -, _ _ .,tate. Zp Code_ r <br /> Contact person. �A tk.C447A ;l_ Ctk tt _._ holt©6 <br /> Storage Facility Name: VM4 (7)7).- <'..Til `k - <br /> Storage Facility A r ss: ej I A Ll I. -f` ' t. k- , <br /> city--. fi14 61 State: L4 Zip Code:_ dVTI­ <br /> Permitted Treatment Fadlity Name: . Gt{cQt%/,�'r,� <br /> Permitted Treatrrt rFacility .'�,[-{iL4410 I <br /> rAddress {' k• . <br /> City ... � = rc� _ � Siate: ='P Code: <br /> List all employee names acrd Was authwized to transport the rts-dical wuste. It not enough space, atbvh information.. <br /> I- Name: hr)cuko (.U?t _ Title: 611:O 7)A /ti�'( /,t/ <br /> 2- Nam*: � C Title: Gt . tui.' /�'u <br /> 3- Name: 71 P C 1AA I J AZA Title: 4 �N <br /> A copy of this exemption and a tracking document shalt Do in employee's paasa:Gtion at all tlmes Mh ham mportirio mocac l waste. to <br /> addltlof% an copito 04 medical WASW recomw shall bo kept on rira at gensrstoez or lw;llu: oris prottsie"OPs far'". <br /> Applicant 51 nature <br /> Title• - - .. , __._ Cate- <br /> t <br /> Do Not WriteBelowThis Line <br /> R.E.H.S. Application Approval:ILAZt,c .__Q+le: 1 / Expiration Vats= 13 /'/ <br /> Em4502 ,"3-96 Date Paid ` Cl/ Cash or Chock# (circle) Acd "t "1A <br /> 1 <br />