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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 l DEC 12 2011 (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION VIRONM HEALTH PERMIT/SEERR VICES 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, transports 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. 1 r Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department FILE COPY Medical Waste Management Program ____ zQO_East-Mai n_Street,_Stockton,CA_9.52023023 Medical Waste Hauler Information ❑ New R1 Renewal Medical Offlcefl3tisiness Name- Lawrence 1'`ar1?1}T Crn.ter & Clinic — Medical Office/Business Address 721 Cal avprng Sr _ J ada rA 95240 City State Zip Code Contact Person: Kathleen Marshall Phone Number: 209 373-2826 Storage Facitity Name: Storage Facility Address: 24GL W. Turner Rd. #45() Lodi , CA 95742 City State Zip Code Permitted Treatment Facility Name: Stericycle s Permitted Treatment Facility Address: 11875 White Rock Rd. 1 _Rancho Cordova. CA 957A2- 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 Barron Title: Lead Receptionist 2. Name: Diane Baba co Title: Clinic Manager 3. Name: Livvy Jackson Title: Registered Nurse A copy of this exemption and a acking document shalt be in employee's possession at all times while transporting medical waste. In addition,all copies of y medical waste records sh e n de at enerator' or health care professional's facility. Applicant Signature: Date: Title: Direc of Quality_- Irmprovement _ 1 DO NOT WRITE BELOW THIS LINE REHS Application Approval: Date: t If Expiration Date: ,Z 1 ✓� 111" Date Paid: tom/ � -1 1 I Cash or heck ""-�iReceived By: _^ EHO 45-01 11/29111 APPLICATION FOR A IMITED QUANTITY HAULING ExEMPTION i