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SAN JOAQUIN COUNTY p�,Y+VIENT <br /> FI /ECS <br /> "ONMENTAL HEALTH DEP lTT RECEIVED <br /> 600 East Main Street, Stockton, CA 95202-3029 p JAN <br /> n� <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:vvvv 'r <br /> \�1r-t3Ra� u <br /> SAN JOAOUIN COUNT`( <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOI o QARTMENT <br /> j1EALfHTo 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: <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 ® 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 KOENIG <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 /> ist all em toe name and titles authorized to transport the medical waste(If more than 3, attach info): <br /> * see a 17c�hed i.sting <br /> 1.Name: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <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 waste.n <br /> mcards kali b IfRe generator's or health care professional's faciiity. <br /> Applicant Signature: Date: 12/18/09 <br /> o z <br /> Title: MARK G. KOEN G, DIRECTOR ' LRMS <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: ffa..Q. Date: 41 /4710 <br /> Expiration Date: 17. /x/14 Date Paid: _N / LA /_0 Cash or heck#: p_ a,LMReceived By: <br /> EHD 45-01 <br />