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ENV RONMENTAL HEALTH DEPARTM T <br /> 1`.d st Main Street, Stockton, CA 95202-30 <br /> J T : J? y <br /> Telephone:(209 468-3420 Fax: (209)468-3433 Web. www!Rj9V-orjeh�""' � 'J <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. <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 n ?C 1 <br /> 600 East Main Street Stockton CA 95202-3029 `. <br /> Medical Waste Hauler Information y0)\CN. <br /> �„,�,1 <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 KOENIG <br /> Phone Number: 2094613184 <br /> Storage Facility Name: DAMERON HOSPITAL ASSOCIATION <br /> Storage Facility Address: 525 WEST ACACIA STREET <br /> STOCKTON CA <br /> City State Zip Code <br /> Permitted Treatment Facility Name: DAMERON HOSPITAL ASSOCIATION <br /> Permitted Treatment Facility Address: 525 WEST ACACIA STREET <br /> S T'OCKTON CA 95203 <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 /> per attached listing- <br /> l. Name: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a trackin document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wa ter ords s all he k t n fii-a' enerator's or health care professional's facility. <br /> Applicant Signature: Date: 12/15/10 <br /> Title: DIRECTOR ALRMS <br /> DO NOT WRITE BELO THIS LINE <br /> R.E.H.S. Application Approval: ' (?,t,� t� Date: )-L / jj/ j-p <br /> Expiration Date: 1 r- Date Paid: 9/. 112 Cash o�jA.2� Received By: <br /> EHD 45-01 <br />