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03/P32/2011 08: 15 20994G1374 f US HEALTHWORKS fAEST PAGE 02/02 <br /> SAN JOAQUIN COUNTY F I L E C 0 P.Y. <br /> ENV i; HEALTH DcPARTMV_NT <br /> 600 East Main Street, Stookton,(3A 95202-3029 <br /> Telephone:(20,1)468.3420,rav(209)46S.1433 Web. .igov.org/elid <br /> .. ....... ...... <br /> APPLICATION F11A LIMITED QUANTITY HAULING EXX MPTION <br /> /pct",'tile ing <br /> Exemption"pursuant to the "Medical Waste.Managementf011 W <br /> To qualifyfor a"Limited Quantity Haut ns <br /> conditions must be met: <br /> The generator or health care pro essional generates less than 20 pouhds of nitdical Waste .per week,itansPlOrt less <br /> than 2.0 pounds of medical waste;-at any one time,maintaim a tracking doo-ament pursuant to Chapter-6 and,thc <br /> - C:following: <br /> generator or parent organization has on file one of the <br /> ti <br /> 1. Medical waste Malic gcinent Plait if the generator or parent orptlization ix a large,duan"�tY 9 enoratOr <br /> or a small quantity gonerator required to register pursuant to Cliapter 4.. <br /> 2.. Inforynation Docume it if the generator or parent organization is a small quantity generator not requirtd <br /> to register pursuant t Chapter 4. <br /> plesise complete the information belov!l and mail with$77.00 fee to: <br /> San Joaquin County Environmental Healltb Department <br /> Medical Waste Management Frogral <br /> 600 East Main Street,Stockton,CA 952 2-3029 <br /> n f,o r m.a t. <br /> Medic ..[l Waste- Hauler <br /> rl New Renewal <br /> (ec,I W6 3ia��tovl <br /> Medical Office/Business Name: <br /> Medical Office/Business Address; F-R-xnOwt <br /> OV) C4161 <br /> City StAte <br /> zip'CO& <br /> Contact Person: k4 <br /> Phone Number: sq(lp -7 <br /> ntcr��Kl We�;T <br /> Storage Facility Name. <br /> IQ-a4 W, <br /> Storage Facility Address: <br /> City _ State Zip-Code <br /> CLA c,(e- <br /> Permitted Treatment Futility Nane- L <br /> Permitted Treatment Facility Addre,�s." ki:"5 FU 1 -SW <br /> rl q <br /> City State Zip Code <br /> List all employee natnes and titles auth rized to transport the medical waste(if more than 5,attach info): <br /> 1.Name: Title., <br /> 2.Name: Title: <br /> 3. Name; Title: <br /> A copy of tbj,.ti;xcinottonand AcIting docuthent shall be In effiployte'N PO"AcssWfl At A tames W.11119"A,5130 <br /> rdaa <br /> g m dt <br /> addition,911 copiesle5 <br /> of me ai aste recoieda.hgg be kept on.file at gcAcriftor's or heolth ogre pr6re-WoAll,�sfaciii <br /> ApplicantjV at <br /> Daatt <br /> e ... <br /> Title: <br /> (j <br /> ]DO N.I T WRITE BELOW T15AS LINE <br /> A.E.14.9, Application Approval: - Date, 3Jir_/, <br /> Expiration Dato: JZ Date Paid; Cash or Check Roccivod By. <br /> HKD 4.1-01 <br />