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s <br /> OF4Him <br /> ulfy � f- <br /> 3• -. :-o, SAN JOAQUIN COUNTY ENT <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEDED <br /> ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DEC 2 3 NO <br /> ... <br /> Rt;Faa` (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> sAx roAraulr!couHTY <br /> I NWIRGNMFNTAL <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION W_ALTHDEPAr2TMENT <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, rnaintains 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 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 /> i register pursuant to Chapter 4. <br /> Please complete the information bellow and mail with $77.00 fee to: . <br /> San Joaquin County Environmental Health Department, AP <br /> T . <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medic-all Waste Hauler Fnformatlon <br /> 0 New IR Renewal <br /> Medical Office/Business Name: Lawrenc_e Famil3r" Center <br /> Medical Office/Business Address v-721 Calaveras St . <br /> Lodi, CA 95240 <br /> ' City State Zip Code <br /> Contact Person: n r Cnnrrl#nnt-nr <br /> Phone Number: <br /> Storage Facility Name: Woodbridge Medical Group <br /> Storage Facility Address: inner Rd. ; Lodi ,, 2 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle <br /> Permitted Treatment Facility Address'. _ 113Z5 .Wtii ce bock Rd <br /> Rancho Cordova, C 95742 <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: Diane" Babayco Title: Clinic"-Manager <br /> 2. Name: Alex Perez Title: .Assistant Clinic Manager <br /> 3. Name: Livvy Jackson Title: Registered Nurs ; . <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be ke on at nerator's or health care professional's facility. <br /> Applicant Signature: Date: �` YMicNT <br /> Title: RECEIVED <br /> i <br /> i DO NOT WRITE BELOW. THIS LINE DEC 23 213 <br /> RENS Application Approval: Date: �I�I�.ENVIReNMJOAQUINENTALCOUNTM <br /> HEALTH DEPARTMENT <br /> Expiration Date: 7-1 /_[ Date PaidCash or heck# �I3�Received By: <br /> EHD 45-01.512!12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO <br />