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"-, 7 2605 08:31 209-468-3841 PHS CLINIC PAGE 021/05 <br /> San Joaquin County Public Health Servic*9 <br /> Environmental Health Division lcoip <br /> Medical VVaste Management Program <br /> APPUCATION FORA LIMITED QUANT17Y HAULING EXEMPTION <br /> To quality for a"Limited Quaritky Haujiy#q ZxiRmpjIW pursuant to the,"�Iadjr,aj ft <br /> condlions must be met: sto Management AcF', the f6liowing <br /> T <br /> I h4D pensmtor oz,health care pmfo.�*ivlai corwrat%kw Ow 20 pounds w, medicatw <br /> wa ,. per vto-vk, a9spo .st rtq. fees11 . <br /> 20 poundia of mqdJ,-,-A vw4utp vt nvY one Ime, mWntabs q trroKng dtxwmiant purevant to Chaptar 6. and the <br /> qLane mtvv(r pamm(,aga6zWjun her,on Tate qjt,, <br /> of Me toftVAng: <br /> I- MiF4kwl Wasto Uanvgemenp pjap q 1p,0;Gnoralw or p*nW orgariziatlan N a large q,�antlty aa~aerator of a Mail <br /> quantitygen"u'llor mquirea to"later pumuarit to Chaphw 4, <br /> If tha- Or Pwent OWIZaVrun W iii sml( quantity ger5'R,1-2tr M1 required to <br /> PLEASE COMPLETE THE UVORMETON BELOW AND MAIL WffH$67 FEE To., <br /> $911-0 Joaquin Couvlly pubic Heafth, <br /> ErrAronm ental Heqlth OlvIsjorl <br /> 304 EVV-aber <br /> Stovkton, CA 95202 <br /> MerOml Wasto Hauler InfbrmatW <br /> 0 New pwpmm,? <br /> kl"I"l <br /> med"Off, Usinese Address._.=I <br /> Clty:. <br /> CorftA Poi Phone P Lazaz—0 <br /> Stora p Really Har TV.— Q-6 <br /> Strwage FOoMy Artd <br /> State: <br /> PemAW TMItTient Fftfity <br /> . Name,---- <br /> Pwmtfted Treatment Facility Addrmss-q: pi j e <br /> 7C� )�els Z LI L) 0 <br /> 'Code.,, <br /> UV'90'erm e*nFir-A-s ar"d"fl(fn, <br /> -NVIn trmsporl ft n*AdW waste- If ropt wwgh nppgv, attach InfonaurAl. <br /> TWO; <br /> 2� Narna: roe, <br /> "ntle, <br /> A vw)y Wkiftwr.r,�V-m um4llf-V'.Wnq 16P ZV". F,r.Shsll be in ornplaywIx vAlgio modioA, watft. In <br /> I%W CM ftw <br /> Applicant Signature:— <br /> Title: fV <br /> Ro-Not Write Below This Line <br /> T-7 <br /> Ap; fes` /0 <br /> �Vl :1-- Cash at Check 91.- _(Vl.d <br />