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SAN JOAQUIN COUNTY <br /> ENw IRONMENTAL HEALTH DEPART'1v&NT PAY v) ; <br /> _ 304 East Weber Avenue, 3rd FIoor, Stockton, CA 95202-2708 F SCEIVED cot <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd fl�L' <br /> Laos <br /> SAN <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMI'MO�tNcajjjVj, <br /> tMLrN p p-Arr,, <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management ActNr?fkA%llowing <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 <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New X Renewal <br /> Medical Office/Business Name: Lawrence Family Center & Clinic <br /> Medical Office/Business Address: 721 Calaveras Street <br /> Lodi CA 95240 <br /> City State Zip Code <br /> Contact Person: Terrie P. Mabalon, R.N _ <br /> Phone Number: 209-373-2860 <br /> Storage Facility Name: Woodbridge Medical Group (WMG) <br /> Storage Facility Address: 2401 West Turner Rd.. Suite#450 <br /> Lodi CA 95242-2185 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Steric cle <br /> Permitted Treatment Facility Address: 1355 i�aou 7T2 ,Z <br /> CA 95-747 9 YaS=� <br /> City 54'tj rf7�117,� 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: Diane Babayco Title: Clinic Manner <br /> 2. Name: Maria Teresa Garcia Title: Lead Receptionist <br /> 3. Name: Elizabeth Castillo Title: FNP <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records sh II be kept on file at generator's or health care professional's facility. <br /> Applicant Signat Date: f;L OF!:5 <br /> Title: r <br /> DO NO/T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: ZI V 1� <br /> Expiration Date: Z/_,�/ Date Paid: , 13 I g Cash or eck . Received By: V4U <br /> E H D 45-01 <br />