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SAN JOAQUIN COUNTY <br /> c� ENVONMENTAL HEALTH DEPARTMAl > <br /> 600 East Main Street, Stockton, CA 95202-3029 t <br /> Telephone: 209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/e d Copy <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 ®EC 2 0 <br /> Medical Waste Management Program 2010 <br /> 600 East Main Street, Stockton, CA 95202-3029 ''�'o�Qur,N <br /> Medical Waste Hauler Information °`�R° vzt�,��,, <br /> ❑ New J1 Renewal <br /> Medical Office/Business Name: King Family Center <br /> Medical Office/Business Address: 2460 E. Lafayette St. <br /> Stockton CA 95202 <br /> City State Zip Code <br /> Contact Person: Kathleen Marshall <br /> Phone Number: (209) 373-2826 <br /> Storage Facility Name: Channel Medical Center <br /> Storage Facility Address: 701 E. Channel St. <br /> Stockton <br /> CA 95202 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle <br /> Permitted Treatment Facility Address: 11875 White Rock Rd. <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: Randy Pinn el 1 i Title: RbyG;ci an Assistant <br /> 2. Name: Virgina Valdez Title: Registered Nurse <br /> 3. Name: David Lopez Title: Registered Nurse <br /> A copy of this exemption and a try king document shall be in employee's possession at all times Nvhile transporting medical waste. In <br /> addition,all copies of medical vva a records shall be kept on file at generator's or health care professional's facility. <br /> Applic Signature: l�%�C .�' Date: <br /> Title: U <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: �- �•.•—_�c�"-ice`• -ADate: / 2fL1 <br /> Expiration Date: / _/�Date Paid: -')-0/ /V Cash or Check#: /�2 0 //y r Received By: 46 <br /> EHD 45-01 <br />