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� . <br /> Sa aquin County Public Health Servi <br /> - Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EMPTZON <br /> Hauling Exepdon" pursuant to the "Medica{Waste Management Ad", the '01Ii <br /> To qualify for a "Limited Quantity 9 rn <br /> conditions must be met: <br /> e generator or health care pro generates less than 2a pounds of trading document pant t4 Chaptter 6, and the <br /> g <br /> than 20 pounds of medical waste at any one time, rnatntains <br /> generator or parent organization has on Ste one of the fallowing: i <br /> 1- <br /> Medica! Waste Management Pfau if the generator or parent organization is a large quantity generator or a small <br /> ired to register pursuant to Chapter <br /> quantity generator requj <br /> 2- <br /> <rarormatidn occ ment if the generator or parent organi=don is a small quantity generator not required to l <br /> register pursuant to Chapter 4. <br /> �MFL-HTE=TI E tN �RiIAAFiflt�= W,ANDTMAtL--W1T7' <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> 1 <br /> Medical Waste Ha er Information i <br /> New C, Renewal <br /> Medical OfFce/Susiness Name:,Cu�M ", Gt l A1v i� �-7 <br /> Medical OfficelBusiness Address: --IState:____r_.—Z:p Code. <br /> City: e;-k Phone — <br /> Contact <br /> Storage Facility Name: 4 <br /> { Starage"Facility Address: / State: Zip Code: �� i <br /> . City, �,.;, <br /> Permitted Treatment Facility Narne' _-- <br /> - ~�Peimitted Treatment Fatsility=r�dd - ss:- <br /> - <br /> List all employee names and/titles authorized to transport the medical waste. If not enough space, attach information. <br /> ,tie: R.N./WD 06 c1_WIC <br /> 1- Nave: �r�l 1 f vJ�s Ttle:r <br /> 2- Name: s F?t ,� � }i ��?.� Title: <br /> 3- Name: �1}; st,���' ►-+,��tc.n� ,a�����ixt� <br /> �Ll b• I} F-iZ Ave medical waste. in <br /> A~ �, 1 ee's Pass health <br /> at all tlme p°�g <br /> A copy of this exemp an a s�d a�c"la ocurnent shall be in emp ay p essional!$ fadFty. <br /> addition. all copies 6f medical wasis <br /> records shall be kept an file at generator's or health rare P <br /> Applicant Sign tures Date:- <br /> i'itle: <br /> Do Vat Write Below This Line <br /> r <br /> Date I� 1 QExpiration Date:r�a�0I <br /> R-E.H.51. Application Approval: <br /> EH4502 la-03-.96 Date Paid t 12.Z- 1 cx� Cash or Chec`t x 22 _(circle) Acct <br />