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=co SAN JOAQUIN COUNTY - <br /> N <br /> n E ONMENTAL HEALTH DEPART F i1/ED <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www DEQ Lain <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIWONMENTAL <br /> HEALTH 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 /> ammw <br /> form tituliel cl mail with fee'I '. <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 /> ❑ New X Renewal <br /> Medical Office/Business Name: DAMERON HOSPITAL ASSOCIATION <br /> Medical Office/Business Address: 525 WEST ACACIA STREET <br /> STOCKTON CA 95203-2484 <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 Facility Address: <br /> City State Zip Code <br /> List <br /> *SEEe employee <br /> name LISTINGuthorized to transport the medical waste(If more than 3,attach info): <br /> 1. Name: Title: <br /> 2. Name: Title: <br /> 3.Name: Title: <br /> A copy of this exemption and a tr cking ume hall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medic wa rec s al be ep on fil at generator's or health care professional's facility. <br /> Applicant Signature: 14Date: 12/15/08 <br /> Title: MARK G. KOENI G D E&T 0 Ile AL <br /> DO NOT WRIT BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / / <br /> Expiration Date: / AL/P4L Date Paid: \ / 2-1Check#: Received By: <br /> EHD 45-01 <br />