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SAN.TOA UIN COUNTY <br /> ry Q FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> l 600 East Main Street, Stockton,CA 95202-3029 <br /> i•� Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> r`A(�FOi2d <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 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$77.00 fee to: PAYMENT <br /> San Joaquin County Environmental Health Department DECEIVED <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 O C T 05 2�Og <br /> Medical Waste Hauler InformationAN JOAQUIN rOUNTY <br /> ENVIRONMENTAL <br /> ®New ❑ Renewal HEALTH DEPARTMENT <br /> Medical Office/Business Name: Lodi Unified School District <br /> Medical Office/Business Address: 1305 E. Vine Street <br /> Lodi CA 95240 <br /> City State Zip Code <br /> Contact Person: Ms. Lynn Vano t t i <br /> Phone Number: (209) 331-7075 (office-Susan) <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: C Q �A,-4oaz S .� oN%-{�_ L%--G rQvjs4- <br /> Permitted Treatment Facility Address: 41&00 /U. hp4vs <br /> oe <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1. Name: Lynn Vanotti Title: School Nurse <br /> 2. Name: Pam Meerdink Title: School Nurse <br /> 3. Name: Mari Hurley Title: School Nurse <br /> A copy of this exemption an racking documen shall be in emplo ossession at all times while transporting medical waste. In <br /> addition,all copies of m di al ste recor be kept on fil ener or's or health care professional's facility. <br /> Applicant Signatur • Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -&/�/04 <br /> Expiration Date:_1/�/�Date Paid:�/ S/�Cash o Check ./42 -`-O Received By: "�•'� <br /> EHD 45-01 <br /> 11/19/08 <br />