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SAN JOAQUIN COUNTY RAYMEN! <br /> E .EI JEI <br /> *NVIRONMENTAL HEALTH DEP MENT N/ <br /> „ '. 600 East Main Street, Stockton, CA 95202-30 4 2010 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.U. - UU <br /> a' F0 `P SAN JOAQUIN COUNTY <br /> FaRr� <br /> ENVIRONMENTAL <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMP'P UNH DEPARTMENT <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 /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New [BRenewal <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 East Channel Street <br /> Stockton, CA 95202 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: SteriCycle <br /> Permitted Treatment Facilitv Address: 1345 Doolittle Drive <br /> San Leandro, CA 94517 <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: Alicia Magana-Duenas _ Title: Medical Assistant <br /> 2. Name: Amber Rice Title: Family Nurse Practioner <br /> 3. Name: Randy Pinelli Title: PA-C, CareLink <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 <br /> rbe'�kept <br /> to�onfile at generator's or health care professional's facility. <br /> Applicant Signature: �/%� .�C7,2- tZ Date: 12-11-09 <br /> Title: Registered Nurse/ ICC <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: �e_ .--• Date: 01 /07/10 <br /> Expiration Date: 10 Date Paid: /�/ Cash or heck_,• `\S 0 S-5 Received By: Ncf- <br /> EHD 45-01 <br />