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oPc,ut c� SAN JOAQUIN COUNTY a =� ENVIRONMENTAL HEALTH DEPARTARNT y <� N .; 304 East Weber Avenue, 3dFloor, Stockton, CA 95202-2708 C<• `P (209)468-3420•Fax:(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd . qC TA p'fta 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. PWMENT Please complete the information below and mail with$70.00 fee to: RECEDE© San Joaquin County Environmental Health Department 9 2004 Medical Waste Management Program JAN 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 eA AQiN oOUNN tt� SAENVIRpNME TMENT Medical Waste Hauler Info`>�`fF - BDEPAR ❑ New R1 Renewal Medical Office/Business Name: KING E A M T 1 Y CENTER Medical Office/Business Address: ?460 East Lafayette S t r e e t Stockton , CA __95202 City State Zip Code Contact Person: T e r r i e P . M a b a l o n , R . N . Phone Number: Storage Facility Name: CHANNEL Medical Center ( CMC ) Storage Facility Address: 701 East Channel Street Stockton , CA 95202 City State Zip Code Permitted Treatment FacilityName: c T c R T r� r i F / RF I MED I CAL -WASTES Perrrutted Treatment Facility Address: 11875 White Rock R o a d 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: V– -gi Pia ua1 dez Title. ter-ed- Nurse—/ GIP 2. Name: Terri e Mabal on Title:Rpgj stPrPd NurcP 3.Name: Eva Ramirez TitleNedical 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 generator's or health care professional's facility. 1 Applicant Signature: �/� , ^c-/V Date: 12 / 12T g-i Title: Registered Nurse DO N T WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: / / Date Paid: / Q /,O'f Cash or eck . 1,�v y Ic Received By: EI D 45-02.001 lonnoo3