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02/01/2007 10:28 FAX 209 751 19aZ COMMUNITY MEDICAL CENTER 2002 <br /> SAN JoAQurN COUNTY P�'l I r <br /> ENVIRONMENTAL HEALTH DEPARTMENT Lti. <br /> 304 East Weber Avenue,3'Floor, Stockton,CA 95202-2708 0t e 0 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www-sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI 7�n <br /> �J'V�PzAj:r-, F <br /> -RA <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the o <br /> conditions must be met: <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$72.00 fee to: <br /> -San.Joaqui3o-Co=ty-En.v.ironmmta;l-Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3d Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New 0 Renewal <br /> Medical Office/Business Name- King FAMily Center <br /> Medical Office/Business Address: 2460 East Lafayette St. <br /> Stockton CA —95202 <br /> city State Zip Code <br /> Contact Person: Terrie P. Mabalon, R.N. <br /> Phone Number: 209-373-2860 <br /> Storage Facility Name; Channel Medjgd-QgGjgL...... <br /> Storage Facility Address: 701 E. Channel Street <br /> Stockton CA 95202 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle <br /> Permitted Treatment Facility Address: 11875 White Rock Road <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- Melissa Goralka. Title: PAC/DSD <br /> 2.Name: Virizinia Valdez Title: Registered Nurse/CP SP <br /> 3.Name.- Vicky Se=a Title: Medical Assistant/CPSP <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 rile at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12/12/2006 <br /> Title: Terrie Mabalom Reeistered-Nurse <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date: 12-/Zq C(p <br /> Expiration Date; J'7_/ JL/�13 GaA-eChcck#: Received By: <br /> EM 45-01 J(T,1�-� <br /> 07131106 REC E I Z007 <br />