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The generator or health care professional generates less than 20 pounds of medical waste per week, transport less <br />than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the <br />generator or parent organization has on file one of the following: <br />1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br />or a small quantity generator required to register pursuant to Chapter 4. <br />2. Information Document if the generator or parent organization is a small quantity generator not required <br />to register pursuant to Chapter 4. <br />Please complete the information below and mail with $72.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202 <br />Medical Waste Hauler Information <br />El New ® Renewal <br />Medical Office/Business Name: SAN JOAQUIN COUNTY HEALTH CARE SERVICES DEPARTMENT <br />Medical Office/Business Address: P. 0. Box 1499/500 WEST HOSPITAL ROAD <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />FRENCH CAMP, QA 95231 <br />City ALDRIDGE <br />INEZ J. <br />(209) 468-6891 <br />SAME <br />City <br />State Zip Code <br />State Zip Code <br />.Permitted Treatment Facility Name: SAN JOAQUIN GENERAL HOSPITAL <br />Permitted Treatment Facility Address: 500 WEST HOSPITAL ROAD <br />FRENCH CAMP, CA 95231 <br />City <br />State <br />Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />I. Name: MAX CERVANTES <br />2. Name: JOSE LOPEZ <br />3. Name: ZACK HERNANDEZ <br />Title: HOUSEKEEPING SERVICE WORKER <br />Title: HOUSEKEEPING SERVICE WORKER <br />Title: HOUSEKEEPING SERVICE WORKER <br />A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medical was ecords shall be kept on file at generator's or health care professional's facility. <br />/I c <br />Applicant Signature: <br />Title: i'`(i ayw, e, s <br />Date: <br />r <br />DO N T W�R.,IITE BELOW THIS LINE <br />R.E.H.S. Application Approval: Date: <br />Expiration Date: 31 / ate Paid: 4 Cash or Check #: j:5 -r Receii <br />EHD 45-01 S old ODS 1 a . <br />07/31/06 <br />A By: %>�J <br />