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04/15/2011 11 : 11 FAX 209 370 1762 CMC LODI RX-REFILL liol <br /> RECENED <br /> SAN JOA IN COUNTY <br /> A PNVIRONMENTAL HEALTH DEPARTMENT <br /> 41 APR 15 2011 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone. (209)468-3420 Fax:(209)468-3433 Web;www.sjgov.org/ehd ENVIRONMENTAL HEALTH <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT18V MIT/SERVICES <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met. <br /> The generator or health care profemional generates less than 20 pounds of medical waste per week, transport Jess <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or patent 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 /> 1 required <br /> 2. Information Document if the generator or parent organization a small quantity generator not require <br /> to register pursuant to Chapter 4. <br /> Please-complete the information below and mail with$77.00 fee to: PA'( <br /> San Joaquin County Environmental Health Department <br /> Medical-Waste Management Program C 2 0 2010 <br /> 600 East Main Street, Stockton,CA 95202-3029 SAN J90AQUW CU <br /> tWRGjVREVr,U" <br /> "F <br /> Medical Waste Hauler Information AL711 oto <br /> New n Renewal <br /> Medical Office/Business Name.- King Famil-y Center <br /> Medical Office/Business Address- 2460 E. Lafayette St. <br /> CA 95202 <br /> stzft zip Code <br /> Contact Person: Kathleen Marshall <br /> Phone Number: (202) 373-2826 <br /> Storage Facility Name; Channel Medical Center <br /> Storage Facility Address: 701 E. Channel St. CA 95202 <br /> Stockton... <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle <br /> Permitted Treatment Facility Address, 11875 White Rock Rd. <br /> Rancho Cordova CA 95742 <br /> City State Zip Codc <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1.Name. p, Pinnpl 11 Title: 1!jajtSjCian A-agnigraint-, <br /> 2.Name: Virgina Val d-@-&-- Title: -Registered Nurse <br /> 3. Name: David Lovez Title: Registered Nurse <br /> A copy of this exemption and a tr"kpking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wa e records shall be kept on File at generator's or bealth care professional's facility, <br /> Applicap3 Signature: <br /> Date: 4P <br /> U <br /> Title: IjJrt-c&­��uaaq t­ <br /> V U <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -IMIWA <br /> Expiration Date: 17 SSI Date Paid: 'W/ID -Cash or Check#:/el 0 Ito V Received By:_45- <br /> EHD 45-Ql <br />