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u <br /> o coG SAN JOAQUIN COUNTY1 <br /> I ENOONMENTAL HEALTH DEP TCy <br /> ��M�EN n <br /> 600 East Main Street, Stockton, CA 952 2 1, 4 �007 <br /> 2 <br /> ;P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ePYR <br /> gc,Foa <br /> SAN JOAQUIN COUNT`( <br /> NVIRONMENTAL <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTILTH DEPARTMENT <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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> Q New (g Renewal <br /> Medical Office/Business Name: DAMERON HOSPITAL.ASSOCIATION <br /> Medical Office/Business Address: 525 WEST ACACIA STREET <br /> STOCKTON CA 95203 <br /> City State Zip Code <br /> Contact Person: MARK G KOENI G <br /> Phone Number: 2094613184 <br /> Storage Facility Name: -same- <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: -same- <br /> Permitted Treatment Facilitv 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 /> —please see attachment- <br /> 1. Name: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a trackin do u nt sh I be in emproyee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wa a re II a ep on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12/21/07 <br /> Title: DIRECTOR AAtuyib <br /> DO N T WR T ELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: /Jul <br /> Expiration Date: J? / Date Paid: -Gask.er Check#: `5 6 $ Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />