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SAN.TOA UIN COUNTY <br /> E1,WONMENTAL HEALTH DEPART&T RZ VEC) <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-270 <br /> FILE C <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web. www.sjgov.org/ehd � � <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION �TIRO EAt"� T . <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following <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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> p New X Renewal <br /> Medical Office/Business Name: King Family Center <br /> Medical Office/Business Address: 2460 East Lafayette Street <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 Medical Center <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: "875 "VV"-=`_ " -' " a- E -Fut <br /> CA -9 4-2, �2 <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: Randy Pinnelli Title: Physician Assistant/CareLink <br /> 2. Name: Melissa Goralka Title: PAC/DSD <br /> 3. Name: Virginia Valdez Title: Registered Nurse <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: J/'M0--& pa,,D Date: /c2 ' 7• oR <br /> Title: I/r-r_ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -Z/ z1_/C� <br /> Expiration Date: -- 2/-31 /-n7 Date Paid: C4&4 heck#: \D&q6q Received By: _ <br /> F 11D 45-01 <br />