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u t _ C_ SAN JOAQUIN COUNTY zL E�RONMENTAL HEALTH DEPART1b,.oNT .'� 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 \�. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transport less than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with$72.00 fee to: San Joaquin County Environmental Health Departmentr� PAYMENT Medical Waste Management Program V R EG F 1 VE n 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202 ' i 2 1 2007 Medical Waste Hauler Information SAN IoAQUINCOUNTY ENVIRONMENTAL ❑New ® Renewal HATH DEPARTMENT Medical Office/Business Name: _Lawrence Family Center& Clinic Medical Office/Business Address: 721 Calaveras Street Lodi CA 95240 City State Zip Code Contact Person: _Terrie P. Mabalon, R.N. Phone Number: 209-373-2860 Storage Facility Name: Woodbridge Medical Group. WMG Storage Facility Address: 2401 West Turner Rd. Suite#450 Lodi CA 95242-2185 City State Zip Code Permitted Treatment Facility Name: Stericycle Permitted Treatment Facility Address: 11875 White Rock Road Rancho Cordova CA 95742 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: Maria Teresa Garcia Title: Lead Receptionist _ 2. Name: Diane Babayco Title: Clinic Manager 3. Name: Tai Tran Title: Physician Assistant 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 medical waste records shall be kept on file at generators or health care professional's facility. Applicant Signature: 1 Date: 12/13/2007 Title: Terrie Mabalon Registered Nurse DO N T WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: Date Paid: 1C,2 I l7 Cash or ck Received By: EHD 45-01 07/31/06