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10 SAN J4&UIN COUNTY PUBLIC F[Mni OVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />Medical Waste Program <br />APPLICAnON FOR A LIMITED QUANTITY HAULING EXEMPTION <br />To qualify for a "Limited Quantity Hauling Exemptiod' pursuant to the "Medical Waste <br />Management Act", you are required to meet the following conditions: <br />1- Your medical office/business generates less than 20 pounds of regulated medical <br />waste per week. <br />2- Your medical office/business transports less than 20 pounds of regulated medical <br />waste at any one time. <br />3- Your medical office/business maintains records of any regulated medical waste <br />transported offsite for treatment and disposal, including the quantity of the waste <br />transported, the type of the waste transported, the date the waste was transported, <br />the name of authorized person that transported the waste and the destination of the <br />waste. <br />PLEASE COMPLETE THE INFORMATION BELOWAND MAIL WrM $67 APPLICATION FEE <br />TO: <br />San Joaquin County Public Health Services PAYMENT <br />Environmental Health Divn RECEIVED <br />P.O. Box 2009 <br />Stockton, CA 95201 JUN 15 1992 <br />SAN jOAQUIN COUNTY <br />LIU HtAL 1 N SLKVICES <br />0 Medical Waste Hauler Inforff,040NMENTAL HEALTH DIVISION <br />Medical Office/Business Name: I ndi Memorial Hospital Home Hpaltb Agel3ry <br />Medical Office/Business Address: 975 S_ Fairmont <br />City: I ndi State: cA Zip Code: cisup <br />ContactPerson: MalcilV13 maki Phone #: I q 7 _g _is <br />Permitted Treatment Facility Name: NZA Permit <br />Permitted Treatment Facility Address: I <br />City: —State, Zip Code: <br />1- Name:Kirklynn JeSse Title:Patie t Care Co-ordinator <br />2- Name: Rowena Patrick Title: Rpgistered Nurse <br />3- Name: Carrol Soren -gen Title: RPgjetPrPd Nijr;p <br />see attachment <br />If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian <br />Storage Facility Name: Lodi Memorial HoSpital Permit #:-HAHQ36021;81 <br />Storage Facility Address: 975 S. Fairmont <br />city: Lodi State: CA -Zip Code: 95240 <br />A copy of this exemption and a tracking document containing the Information above shall be In <br />employees possession at all times while transporting medical waste. In addition, all copies of <br />medical waste records shall be ept on file at your facility. <br />e: Z A_del� Date: <br />Applicant Signatur4i�� <br />R.E.H.S. Application Approv/: L -td_ Date: 1012411f9l <br />EH 45 02 12-2-91 <br />