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fY PAYMENT <br /> RECEIVED <br /> j '�IVIRONMENTAL HEALTH DEPil� 'MENT <br /> '- 600 East Main Street, Stockton, CA 95230 4 Q <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web: www p <br /> SAN JOAQUiN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI yII?O <br /> TH l7EPAFiTM L <br /> ARTfVIENT <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, 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: I <br /> i <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 1 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information ? <br /> ❑ New g3 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 Croup (WMG) <br /> Storage Facility Address: Z401 West Turner Road Suite #450 <br /> Lodi CA 95242-2185 <br /> City State Zip Code <br /> i <br /> Permitted Treatment Facility Name: SteriCycle <br /> Permitted Treatment Facility Address: 1345 Doolitle Drive <br /> --_San_.r dre 94577 <br /> City State Zip-Code <br /> i <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: Elizabeth Castillo Title: Family Nurse Practitioner <br /> 3. Name: Jobana Santoyo Title. Medical Assistant <br /> i <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 shall be kept on file at generator's or health care professional's facility. i <br /> ��f - <br /> Applicant Signature: � 7 ��h• %tel/ Date: 12-08-09 <br /> Title: Registered Nurse, I.C.C. <br /> DO NOT WRITE BELOW THIS LINE <br /> i <br /> R.E.H.S. Application Approval: C .a. Date: -61 /07/1V <br /> ! <br /> Expiration Date: lZ-/3 /0 Date Paid: /�A 0 Cash o eck k ��S 0 Received By: %-T=%- <br /> i <br /> ERD 45-01 <br /> i <br />