Laserfiche WebLink
10� <br /> /06/2001 07:34 2094683433 FIFTH FLOOR PAGE 02 <br /> S Joaquin County Public Health Senos <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "limited Quantity Hauling Exemption" pursuant to the"INAedical Warks Management Ail:°, the Following <br /> conditions frust be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transparts 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 Pfau if the generator or parent organization is a large quantity generator or a small <br /> 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 /> register pursuant to Chapter 4. — <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WI S67 FEET <br /> — �_- <br /> San Joaquin County Public Health Services AUG 6 2001 <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New G Renewal <br /> ,Medical OfficelBusiness Name:. COMMUNITY MEDICAL CENTERS/CHANNEL MEDICAL CENTER/HOMELESS PROGRAi4 <br /> ,Medical Office(Business Address: 701 E. CHANNEL STREET <br /> State: CA Zip Code: 95202 <br /> City; STOCKTON <br /> Contact Person: MARC SMITH Phone 944-4703 <br /> Storage Facility Name: CUNNEL MEDICAL CENTER <br /> Storage Facility Address: 701 E CHANNEL STREET <br /> State:, Tp Code: 95202 <br /> City: STOCKTON <br /> Permitted Treatment Facility Name= <br /> Permitted Treatment Facility Address: 11875 WHITE ROCK ROAD <br /> City: RANCHO CORDOVA State: CA Z1p Code: 95670 <br /> L ist all employee names and titles autharixed to transport the medical waste. If not enough space, attach infarmat;on. <br /> 1- Name: RANDY PINNELLI Title: PHYSICIAN ASSISTANT <br /> 2- Name: DENISE RIGS Title: MEDICAL ASSISTANT — <br /> 3- Name: STEPHANIE WICKS Title: D1111 SE PRACTLTIONER — <br /> TAI TRAN PHYSICIAN ASSISTANT <br /> A copy of this exemption and a traciting doeximent s U be in em loyee's possession at ail dress white taaassp�ting waste_ In <br /> addition. all copies of medical cords shall kep n <br /> at gene2icr's or health care pnss�ooraPs ��EY- <br /> Applicant Signature: <br /> Title: CHIEF OPERATI NS OFFICE paw: 7 ! 6 / 01 <br /> Do Not write Below This Line <br /> R.E.H.S. Application Approval: Date: ! /01 Expiration Date: a / � ��� <br /> &J4502 1"3-96 Date Paid 5f I i h or Check = S5�(v��(Circle) Acct <br />