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elrrOAQ <br />AN w <br />ilk <br />SJUIN COUNTY <br />o�q.. 12— KedZC11 <br />UX. <br />�,. •2 ENVIRONMENTAL HEALTH DEPARTMENT <br />C: ' Y, ' i <br />^" '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />(209) 468-3420 Fax: (209) 4640138 Web: www.sjgov.org/ehd <br />��xoa <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, transports 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 />Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a <br />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 to <br />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 "PROVE <br />Medical Waste Management Program ! <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />❑ New <br />Medical Waste Hauler Informatlon <br />9 Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address <br />Contact Person: <br />Phone Number: <br />DAMERON HOSPITAL ASSOCIATION <br />525 WEST ACACIA STREET <br />STOCKTON CA 95203 <br />City State Zip Code <br />MARK G. KOENIG <br />2094613184 <br />Storage Facility Name: DAMERON HOSPITAL ASSOCIATION <br />Storage Facility Address: 525 WEST ACACIA STREET STOCKTON CA 95203 <br />City State Zip Code <br />Permitted Treatment Facility Name: DAMERON HOSPITAL ASSOCIATION <br />Permitted Treatment Facility Address: 525 WEST ACACIA STREET STOCKTON 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 />1. Name: -Per attached listing Title: <br />2. Name: Title: <br />3. Name: Title: <br />A copy of this exemption and a trac ing, doc ment s at be i e _ loyee's possbssion at all times while transporting medical waste. In addition, all copies of <br />medical waste records shall b kept n I ener or 1 e professional's facility. <br />Applicant Signature: _kADate: 12/10/12 <br />Title: MARK G. KOENIG, DIRECTOR ALRMS <br />DO NOT WRITE B OW THIS LINE <br />RENS Application Approval: Date:l]�Il?� <br />Expiration Date: rL 1 1A-) Date Paid: /a_/ /7/ Cash o heck . 1.7g Received By: <br />EHD 45-015012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />