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JUL 06 2004 12.23 FR MRXIM HEALTH CRRE 937 294 3195 TO 14109101723 P.02i02 <br /> u 1/ U0/ LUuY Uo.u7 r"1l-' 11-1 1-"VWN 1:4 <br /> SAN JOAQUIN COUNTY <br /> a EwRoNMEmAL HEALTH DEPARTMENT <br /> w; V <br /> 304 East Weber Avenue,3`°Floor,Stockton, CA 95202-2708 <br /> •(209)468-3420-Fax:(209)468-3433- Welx www.co.san-joaquin.c:a.us/ehd <br /> JUL 0 8 2004 <br /> APPLICATION FOR A LEVIITED QUANTITY HAULING EXEWMWENT HEALTH <br /> qualify Quantity g P P oFEent� , jk lowing <br /> To uali for "Limited uattti Hauling Exemption"pursuant to the"Medical Waste Manaoement c <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week;transport less <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the following: <br /> 1_ Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br /> or a small quantity generator required to register pursuant to Chaptcr 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$70.00 fee to: <br /> 'San Joaquin-County-En hronmental Health Department <br /> Medical Waste Management Program <br /> 304 East Webex.Avenue,PFloor,Stockton,CA 95202 <br /> Medical Waste Hauler Informlation <br /> 214ew D Renewal <br /> Medical Office/Business Name: v,(k c s <br /> Medical Office/Business Address: l Y c. L b 5'E <br /> jA& �") ' 4. 2 1;,RO`1 <br /> City State Zip Code <br /> Contact person: _ �C (��' r nsZ n <br /> Phone Number: vZy q — �rl <br /> Storage Facility Nance: C <br /> Storage FaciLlity Address: i \��l WWO( <br /> City State Zip Code <br /> ,Permitted Treatment Facility Name_ )Az+ c=. Clt- --��e G t\,c* A vx,,, <br /> Permitted Treatment Facility Address: 1 5 W VNkc (�c <br /> C6 vtC(- Pt✓t City state Zip Code <br /> List all employee names and titles authorized to transport the medical waste(7f more than 3,attach info): <br /> 1. Name: L-0 l S r��-kv1 Cc— Title: <br /> 2. Name: ( e l`e— Title: n% <br /> 3.Name: 1cki re Sole-nhsol-I Title: V N <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while trhnsporting medical wasm In <br /> addition,all copies of medical w 01 <br /> o records sh 11 be Kept on file at generator's or health care professional's facility. <br /> Applicant Signature: - y bate: -7 2,60 LI <br /> Title: __ �Urc�rs��. S(?ec�cEli 51- <br /> DO NOT WRITE BELOW THIS LINE <br /> ILE.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: / / Cash or Check# Received By: <br /> EM 6s02-001 <br /> 1 oM4003 <br /> JUL 06 2004 12:13 2094683433 PAGE.02 <br /> ** TOTAL PAGE.02 <br />