Laserfiche WebLink
SAN.JOAQUIN COUNTY ,l a <br /> -< C <br /> EIV ONMENTAL HEALTH DEPART T <br /> 304 East Weber Avenue, 3dFloor, Stockton,CA 9520208 <br /> n() <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sj <br /> APPLICATION FOR A LIMITED QUANTITY HAULING ftK&v[P(I'p <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Wka&/W1i k6mEn!-fLAct'#;i the following <br /> conditions must be met: PERPO1 i JSER1/! ES <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: <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 $70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, P Floor, Stockton,CA 95202 <br /> . Medical Waste Hauler Information <br /> ❑New E3Renewal <br /> Medical OfficeBusiness Name: KINGA F A M T 1 Y CENTER <br /> Medical Office/Business Address: 2460 East Lafayette Street- <br /> Stockton , CA 95202 <br /> City State Zip Code <br /> Contact Person: T E R R I E P . M A B A L O N , R . N . <br /> Phone Number: 209/ 944-4160 e x . <br /> Storage Facility Name: CHANNEL MEDICAL CENTER ( CMC ) <br /> Storage Facility Address: 701 E . Channel Street <br /> Stockton , CA 95202 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S T F R T c Y C( F <br /> Permitted Treatment Facility Address: 118 7 5 W h i t e R o c k R o a d <br /> Rancho Cordova , CA 95742 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1.Name: Virginia Valdez Title: gegistered Nurse/ CIP <br /> 2.Name: Terrie P . Mabalon Title: Registered Nurse/ CIP <br /> 3. Name: Vicky Segura Title: Medical Assistantl CIP <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. <br /> Applicant Signature: Date: pec . 10 . 2004 <br /> Title: Terri e Mabal on , Registered Nurs <br /> DO NO' WRI BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: X21 / <br /> Expiration Date:�/-3�/Q�Date Paid: 12/_k--�l� Cash or Check#:_?-(Y3 3_ Received By: L <br /> EHD 45-02-001 <br /> 10/7/2003 <br />