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02/26/2001 13:31 2094683433 FIFTH FLOOR PAGE 02 <br /> 6001 doaquin.County Public Health Servic-..s <br /> Environmental Health Divfsian <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY E-fAULING EXEMPTION <br /> To qualify for a "Limited Cuantity Hauling Exemption" pursuant to the"Medica!Waste Management AcV. ttie foftowing <br /> conditions must Fe -net: <br /> The generator or health care professional generates less tf'•.an 20 pounds of medical waste per week, tttspores less <br /> than 20 pounds of medical waste at any one time, maintains a cracking document pursuant to Chapter S, and the <br /> generator or parent organization has an file one of the fallowing: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Informadon Coccrment if the generator or parent organization is a &-nail quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFOR.MATMN BELOW ANIO MAIL WITH S6"7 FE ►0: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division P,_C p � <br /> Medical Waste Management Program FiE iVE D <br /> 304 E Weber Ave <br /> Stockton, CA 95202 fl"tR 0 2001 <br /> �i1J 'i- OD/�-790 <br /> Medical Waste Hauler Information <br /> xR New C Renewal F'� <br /> Medial CM, ce/Eusiness Name:. St. Helena Hospital_ (- .Purer foruPa1�i, <br /> ,Medical Office/Susiness Address: 650 Sanitarium Road <br /> City: Deer Park State: CA Zip Code:94576 <br /> Contact Person: Hazel Barber RN Phane-4r- 707 963 6387 <br /> Storage Facilit/ Name: St. Helena Hospital <br /> Storage Facility Address: 650 Sanitarium Road <br /> Cir: Deer Park State: CA Zip Code: 94576 <br /> PermiCted Treatment Facility Name: St. Helena HOSDital <br /> Pa-mit;ed Treatment Facility Addrass: same as above <br /> State: Zip Code: <br /> List all employee names and titres authorized to transport the medical waste. if not enough space, attach information. <br /> I_ Name: Hazel Barber RN Title: Cnordinatnr_ u Rt <br /> 2- Name: Lisa Hellie MS Title: HH?,Alth F , rnr <br /> 3- Name: Title_ <br /> A Copy of this exam;;dcn and a tracking documerx shaft be in emplcyaws passesslan at an times viae tzar porthg medicsl waa.-te. In <br /> addItfon. all caples of medical wasm m=1Y:shall he kept an fae at goner wez or heaMi c ue mwessfcr%ars faes'tity. <br /> Applicant Signature: <br /> --i�,e: Coordinator, Heart At Risk Daze: ?.1$_,q./n i_/ - <br /> Co Not Write Below i his Line <br /> fLE.HS. Application Approval: Date:3 11ZtV Expiration 0atedZ4-3/f 0 <br /> EH4502 ra o3-96 Dace Paid OJT/ e / C.-s1 c C-ier (cirde) Ac=__ ,1 , <br />