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PpU1,N_ � o SAN JOAQUIN COUN'T'Y E ONMENTAL HEALTH DEPAR T 304 East Weber Avenue, 3dFloor, Stockton, CA 9 C j{,0,8 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgts� rg/ehd ��JFOR� APPLICATION FOR A LIMITED QUANTITY HAULINaVX-h IMbN To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Was 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 $70.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 Medical Waste Hauler Information ❑ New [2] Renewal Medical Office/Business Name: LAWRENCE FAMILY CENTER & CLINIC Medical Office/Business Address: 721 Calaveras Street Lodi , CA City State Zip Code Contact Person: T E R R I E P . M A B A L O N , R .N . Phone Number: 209/ 944-4760 ext . #4672 Storage Facility Name: W n n D R R t D G E MEDICAL GROUP ( W M G) Storage Facility Address: 2401 West Turner Road Suite #450 Lodi , CA 95 - City State Zip Code Permitted Treatment Facility Name: S T ER.LC-Y-C L E Permitted Treatment Facility Address: 1_I s- 5 W h i t P 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): l. Name: _Rpth Rutchpr Title: R .N . / Clinic Manager 2. Name: Martha Leonardini Title: Registered Nurse. 3.Name: Alicia Magana- Duenas Title: Medical Assistan 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. Applicant Signature: `� - _ ,� Date: --12/ 10 / 04 Title: Tp -ron' R tered Nurse DO NOT WR T FLOW THIS LINE R.E.H.S. Application Approval. Date: jy_j--ay-0�1 Expiration Date:- / Date Paid: /� / p�Cash or Check#:�7_ 7ro Received By: EHD 45-02-001 10/7/2003