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RECEED <br /> OP4Ut� C / <br /> .oG S � ILI U I ENT it <br /> �H, { ENVIRONMENTAL HEALTH DEPARTMENT MSR02 <br /> �'� <br /> '. 600 East Main Street, Stockton, CA 95202-3029 <br /> P (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd ENVIRONME <br /> J .� EBVM%RVIC IL HEALTH <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION pp <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Mar � 49t Ag", t1-ie fk;A4fig <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports 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 or a <br /> 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 to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to:,,d . <br /> San Joaquin County Environmental Health Department <br /> 1 Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medlcal Waste Hauler Informatlon <br /> D New N Renewal <br /> Medical Office/Business Name: Lodi Unified School District/Health Services <br /> Medical Office/Business Address 1305 E. Vine St. <br /> Lodi, CA 95240 <br /> City State Zip Code <br /> Contact Person: Lynn Vano t t i, RN <br /> Phone Number: C: 609-1708; W• 331-7075 (Susan) <br /> Storage Facility Name: Clean Harbors <br /> Storage Facility Address: 7850 South R.A. Bridgeford St. <br /> City State Zip Code <br /> Stockton, CA 95206 <br /> Permitted Treatment Facility Name: "same as above" <br /> Permitted Treatment Facility Address: <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 Vanot t i Title: RN <br /> 2. Name: Deborah Tyler Title: RN <br /> 3. Name: Clare Woznick Title: RN <br /> Roberta McConahey RN <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records sh II kept or�file ge erator's or heal re professional's facility. <br /> -- — - - - <br /> Applicant Signature: Date: <br /> Title:_ Coordinator, Special Services Health <br /> n DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval a_%- t �� Date: d/ 2,!,/Z <br /> Expiration Date: it/ 61 IL Date Paid: 1 / g/ Z Cash or Check#: ` Z g5W 1 Received By: t <br /> EHD 45-0111129/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />