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3AN JOAQUIN I.DUNTY <br /> EJ&RoNMENTAL HEALTH DEPARTJWT <br /> East Main Street, Stockton, CA 95202-3 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd <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. b W 00t73([T <br /> Plegse complete the irfcl~ntation below and rvail with Q77.00 fee to: �*d)24pZIt <br /> San Joaquin County Environmental Health DLpartment ptjLo037937 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> rl New p Renewal t <br /> Medical Office/Business Name: Gleason House <br /> Medical Office/Business Address: 423 S. San Joaquin St. <br /> Stockton, CA 95203 <br /> City State Zip Code <br /> Contact Person: Kathleen Marshall <br /> Phone Number: (209) 373-2826 <br /> Storage Facility Name: Hammer <br /> Storage Facility Address: 1721 E. Hammer Lane, Suite A <br /> Stockton, CA 95210 <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 Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): <br /> 1. Name: Jonalyn'Vergara Title: Clerical Assistant <br /> 2. Name: Diane Fountain Title: Case Manager <br /> 3. Name: Angie Segura Title: Medical Assistant <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 ste records shall be kept on file at generator's or health care professional's facility. <br /> PAYMENT <br /> Appl' ant Signature-- Date: l RECEIVED <br /> Title:_b\( CtUV 01UNll� <br /> OCT 2 4 2011 <br /> DO NOT WRITE BELOW THIS LINE SAN JOAQUIN COUNTY <br /> � ENVIRONMENTAL R.E.H.S. Applic it�pproov Date: g yt_TH DEPARTMENT <br /> Expiration Date: Date Paid: Cash o heck#• AD t 14.3 Received By: L� <br /> EHD 45-01 <br />