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JAN-03-2007(WED) 16; 12 LMH Facilities Management (FAX) 339 7672 P. 004/004 <br /> San Joaquin County Public Health Services <br /> <'nvironmental Health Division <br /> Medical Waste Management Program <br /> MEDICAL WASTE, TRACKING DOCUMENT <br /> (To be used with the"Limited Quvztity Hauling EXemption,,form only) <br /> Medical OfFlce/Business name: <br /> LodiMemorial Hos ital <br /> Medical Office/Business Address: 975 S.Fairtraont Avenue <br /> Phone Number: 209.339-7668 <br /> Contact Person: Ga Ie Moses <br /> Name of Person I4auling Medical Waste: <br /> (Must be person authorized on "Limited Quantity IIauling P_iemption"application) <br /> Quantity of Medical Waste PTauled: <br /> (Not to exceed 20 pounds/week) Bate Mauled: <br /> Type of Medical Waste Hauled: <br /> Permitted Treatment Facility Name: Sanitec USA Inc. <br /> Permit#: TS/OST 2Q <br /> Permitted Treatment Facility Address: 9065 Norris Avenne <br /> City. Sun Vane State: CA <br /> Zip Code: 91`2 <br /> Date Medical Waste Received: Not A .licable <br /> Signature of Authorized Treatment Facility Representative: <br /> � Not,�. licable <br /> 'Citle: Not A licahle <br /> Date:Not Ap lic3bic <br /> I~R.L OUT INFORMATION BELOW ONLY IF MEDICAL WASTE IS NOT BEING TRAM <br /> DIRECTLY TO A TREATIVIEN'r FACILITY [i.e.,Medical Waste is bei S?OIZTED <br /> permitted storage facility or(2.)a veterinarian or a home health care nurse s hauling <br /> medical waste <br /> to own facility.] back <br /> Storage Facility Address; Lodi Memorial Hj)s iL_d <br /> Permit 00585 <br /> Storage Facility Address; 975 Face wont Avenue <br /> City: .Lodi <br /> State: CA Zip Code:�95240 <br /> Date Medical Waste Received: <br /> Signature of Authorized Storage Facility Representative: <br /> X C a Ie Moses <br /> Title:Safer Security►Clf er Date: <br /> IIAUI,ER SMALL LEEP A COMPLETED COPY OF " <br /> Z IIS D(jC ,.NT ON FIT.E FOR 3 YEARS <br /> Eh 45 03 09-27-95(gm;Form,Med WAste Tracking 2007.doc) <br />