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AIUIN SAN JOAQUIN COUNTY PAYMENT _ RECEIVED tNVIRONMENTAL HEALTH DEPARTMENT ? DEC 8 2011 600 East Main Street, Stockton, CA 95202-3029 (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd SAN JOAQUIN COUNTY ENVIROMENTAL '9CIFORta APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOWEALTH DEPARTMENT To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to regiStcr rnwirci iant to Chanter d; Please complete the information below and mail with $77.00 fee to: FILE COPAY San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Informatlon ❑ New 7 Renewal Medical Office/Business Name: Dameron Hospital Association Medical Office/Business Address 525 West Acacia St. Stockton CA 95203 City State Zip Code Contact Person: Mark Koenig Phone Number: 209 . 461 . 3184 Storage Facility Name: Dameron Hospital Association Storage Facility Address: 525 W. Acacia St. Stockton, CA 95203 City State Zip Code .Permitted Treatment Facility Name: Dameron Hospital Association F _eat a Facility Address: 525 W. Acacia St. _ F EftliittG%7 �ca�meri� acl l,y uie.3. Stockton CA 95203 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info):—per attached 1. Name: Title: listing- 2. isting- 2. Name: Title: 3. Name: Title: A copy of this exemption and a tracking doFument shall be in erlployet,s possession at alLtimes while transporting medical waste. In addition,all copies of medical waste records shall be keptpr essional's facility. ME:;P Applicant Signature: (&VDate: 12/7/2 011 Title: Director ALRMS DO NOT WRITE BELO THIS LINE REHS Application Approval: ` Date: 1I Z/ 111 Expiration Date: / I / I'L Date Paid: IZ/ / I I Cash ore:: Received By: EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION