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SANJ416N COUNTY PUBLIC HEALTH CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Medical Waste Management Program <br /> APPLICATION FORA LffvffTED QUANTITY HAULING EXEMPT[ON <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste <br /> Management Act", you are required to meet the following conditions: <br /> 1- Your medical office/business generates less than 20 pounds of regulated medical <br /> waste per week. <br /> 2- Your medical office/business transports less than 20 pounds of regulated medical <br /> waste at any one time. <br /> 3- Your medical office/business maintains records of any regulated medical waste <br /> transported offsite for treatment and disposal, including the quantity of the waste <br /> transported, the type of the waste transported, the date the waste was transported, <br /> the name of authorized person that transported the waste and the destination of the <br /> waste. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WrW$67 APLICATION FEE <br /> TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division PA� <br /> P.O. Box 2009 Recel <br /> Stockton, CA 95201 "y <br /> SAN J w- 19,9 <br /> Medical Waste Hauler Information ENVR �qAt H C01 Nt-y <br /> LTyELNE4 <br /> Medical OceBusiness Name: Dameron Hospital Association VSn <br /> y <br /> Medical Office/Business Address: 525 West Acacia Street <br /> City: Stockton State:CA Zip Code:95203 <br /> Contact Person:Mark G. Kckenig, M.S. Phone <br /> Permitted Treatment Facility ame: Dameron Hospital Association Permit #:66987 <br /> Permitted Treatment Facility Address: 525 West Acacia Street <br /> CityStockton State:CA Zip Code: 95 0'2 <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name: Charlotte Sturges Title: OHS-Director of Oterations <br /> 2- Name: Martha Ingraham Title: OHS-Marketing Representative <br /> 3- Name: Leigh Kincaid Title: OHS-Clinic Coordinator <br /> If transporting medical waste to a permitted storage facility for consolidation purposes or I veterinarian <br /> or home health care nurse transporting medical waste back to own facility, please complete the following: <br /> Storage Facility Name: Dameron Hospital Association Permit #: 66987 <br /> Storage Facility Address: 525 West Acacia. Street <br /> City: Stockton State: r.A Zip Code: 95203 <br /> A copy of this exemption and a tracking document containing the Information above shall be In <br /> employees possession at all times while transporting medical waste. In addition, all copies of <br /> medical waste recorPark <br /> kept on'I'lle at your facility. <br /> Applicant Signature: Title: Safety ChairmanDate:4 0 3 <br /> R.E.H.S. Application Approval: Date: 4� 1115�?' <br /> EH 45 02 12-2-91 <br />