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JUL 07 2004 14:58 FR T 94Ge3433 P.02/02 <br /> -J� J1 JJ I <br /> o��o�auu� Ua.ua- -- «�� f1+ ii^I r�vVn -1�1rCJ h'.U�dMU'e <br /> �. u� 4114 <br /> SAN JOAQMN COUNTY <br /> ENVUtONMEMAL REALTH DEP, Ia ANT <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA.95202-2705 <br /> (209)468-3420'Pas:(209)468.3433-ld!eb:uww.co.saA-j0&quin-ca_AVthd <br /> APPLICATION FOR,A,LrvHTED QUANTITY"HAULING EXEMPTION <br /> TO qualify for a"'Limited Quantity,F]auling Exemption"pursuant to the"Medical Waste NVbmagement�ct",the following <br /> conditions must be met <br /> The ge=axor or health care professiomal generates less than 20 pounds of medical waste per week;tratlsport less <br /> thorn 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or parent orrmization has on file one of The follo ring: <br /> 1, Plan if the generator or parent organization is a large quantity generator <br /> or a small quantity gencrator required to register pursuant to Chapter 4- <br /> 2. Itf0mation Document if the generator or parent organization is a small quantitynot required <br /> to register pursuant;to Chapter 4. <br /> )Please complete the information below and mail with$70.00 tee to: <br /> San J*aquin•CountyF;0ironmerotal Health Drpartmcnt <br /> Medical waste Management Program <br /> 304 East Weber.Avenue,PFloor,Stockton,CA 95202 <br /> rte' Medical Waste Hauler Information <br /> ! 'N + ©Renewal <br /> Medical OIl[ice/Business Name; rti S <br /> Medical OfficeMmsiness Address: v . <br /> v1 <br /> City State zip Cade <br /> Contact person: �e r r)S6 Y1 <br /> Phone Number: zk l 3 <br /> Storage Facility Name: 4` ��� �. r.(-� — <br /> Storage FacklityAddress: —L —W. \'k Ai._. C-R,(,_ <br /> ata' Stake .Zip Code <br /> ,Permitted Treatment Facility Nance: 3A ce yk c 4- <br /> Permitted.Treatment Facility Address: 1 �c c.l L <br /> CO vL G� A a-1R City State zip Code <br /> List all employee narues and titles authorized to transport the edi cal waste(If more e=3,attach into): <br /> .-- alF� 1� <br /> 1.Name: l S i�ttt-lVl L.�.. Title: <br /> 2.Name: l L o Tine: 1� <br /> 3.Name: C�o,t c e -7 o st aks o�g — Title:LV_N <br /> A copy of this exemption and a tratRing docutneat shall be iq 2mpioyee's possession at all timeswhtle tmosparting medical W&SM In <br /> addition,all copits of medical w e records sh 1l he kept on role at generstar's or health tare professional's facility. <br /> Applicant Slgmature: Date; o)Li <br /> Title: 5)e,-L(kL 15 1- <br /> DO NO WRITE OW THIS LINE / <br /> ",H.S.Application Approval'. ate: <br /> Expiration Date,�2/3�/ am P1idc /'/dash or Check#:�����Rcccitrod t3y. <br /> rM 49-02.001 <br /> 10012003 <br /> JUL 06 2004 12'13 2094683433 PAGE.02 <br /> * TOTAL PRGE.02 * <br /> ** TOTAL PAGE.02 <br />