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JUL 07 2004 14:58 FR TO 912094683433 P.02/02 <br /> I U <br /> of,run1,cuu�+ uo.ua aur+ �le�y(4.) 1-.lJd�i�� <br /> t-Vvn ri..vc CtL <br /> SAN JOAQMIv COUNTY <br /> a; K ENVaONMEMAL 11EALTH DEPARTMENT <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> .(209)468-3420-Far.-(Z09)46S-3433•We6:anvw.co.sanrjoaquin ca-Wthd <br /> APPLICATION FOX,,A,L i ICTLD QUANTITY HAULING EXEMPTION <br /> To qualify fora'Limned Quantity Hauling Exetnpron"pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met <br /> The generaror or health care professiowl generates less than 20 pounds of medical waste per week transport less <br /> than,20 pounds of medical waste at arty one time,maintains a tacking doc==t pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the following: <br /> l• Medical ftsre Management Plats if the generator or parent organization is a large quantity generator <br /> or a small quantity geumlor required to register pursuant to Chapter 4_ <br /> 2. Aformarion Document if the generator or parent organization is a wrall quantity generator not rtquired <br /> Uw 0 to register pursuant to Cbaptcr 4. <br /> DDIirlease complete the iaoxmaf on below and mail with 570.00 fee to= <br /> n.Joaquin•County:Etivironrn=W Health Dcpartmcnt <br /> Medical Waste Management Program <br /> 304 East Weber.Awenue,3'dFloaz,Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> D Renewal <br /> Medical Office/business Name: G S <br /> Medical Office/Business Address: 1 v <br /> City State ,Zip Codc <br /> Contact Person: _ 75-61.1 6e r rush v1 <br /> Phone Number: 9101 — -9 V"]— <br /> Storage Facility Name: �� -t"• C. c l Q <br /> Storage Facklity Address: 'S W (_U_ U 5� <br /> City Stare Zip Code �O <br /> 'Permitted Treatment Facility Name: ji ,Qi c CSC 6svt}mac-4- <br /> Permitted Treatment Facility Address: 1 k�e CLL <br /> q, *IT5— 55d (� Vr <br /> Co A City State Zip Code <br /> List all employee narues and titles authorized to transport the ujetii cal waste(If more than 3,attach info). <br /> 1.Name: l S q(-lq CC_ Title: <br /> 2.Name: L �1 C`o - Title: <br /> 3.Name: cti` rte_ o s-e r�11S o✓1 Title: V N <br /> A copy of this exemption and a trading doculn tat Shall be in employee's possession at all times while tmaspurting.medical wasm in <br /> addition,a)1 topics of1"0dical wt records sh 11 be ktpt on rile at generstor's or health tare proressional's facility. <br /> Applicant Siggature: rfubL_ Date.: -2 200 L� <br /> Title: YtAVC kTl�n; 1 5)79 e cl�l 1 5l- <br /> U 6 - <br /> D N0 'PYRITE R OW THIS LINE <br /> H.S.Application Approval ate: <br /> Expiration Date: / / are Paid: Tl / ash or Cheekgcceived 13y <br /> 61 D 4542-001 <br /> JUL 06 2004 12=13 �l Y 1p� "/ 2094683435 PAGE.02 <br /> / * TOTAL, PAGE.O2 >k* <br /> ** TOTAL PAGE.02 ** <br />