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i � � � :r' ry +yp g.'^ '�{ r•'ill °• _ �o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 FORr' (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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 register pursuant to Chapter 4. Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department ®`I�i Medical Waste Management Program jwP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information 0 ❑ New Renewal Medical Office/Business Name: DAMERON HOSPITAL ASSOCIATION Medical Office/Business Address 525 WEST ACACIA STREET STOCKTON CA 95203 City State Zip Code Contact Person: MARK G. KOENI G Phone Number: 2094613184 Storage Facility Name: DAMERON HOSPITAL.:ASSOCIATION Storage Facility Address: 525 WEST ACACIA STREET STOCKTON CA 95203 City State Zip Code Permitted Treatment Facility Name: DAMERON HOSPITAL ASSOCIATION Permitted Treatment Facility Address: 525 WEST ACACIA STREET 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): 1. Name: -Per attached listing Title: 2. Name: Title: 3. Name: Title: A copy of this exemption and a trac ing doc ment s al be i e _loyee's possIssion at all times while transporting medical waste. In addition,all copies of medical waste records shall b kept n 'I ener or I e professional's facility. Applicant Signature: - Date: 12/10/12 Title: MARK G. KOENIG, DIRECTOR I ALRMS DO NOT WRITE B OW THIS LINE REHS Application Approval: Date: �lO-Laet Expiration Date: lI Date Paid: /�l l7 /�a Cash o heck Received By: Y EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION