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Aq•U I ly <br /> �Q1\1� 0 SAN JOAQUIN COUNTY 14 MAMM <br /> N. ENVIRONMENTAL HEALTH DEPARTMENT SAN - 3 2012 <br /> .. 2{ <br /> • 600 East Main Street, Stockton, CA 95202-3029 <br /> • - <br /> • (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> cq��oR �P PERMIT/SERVICES <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, transports 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 or a <br /> 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 to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> FlUo <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 InforMC-"I-e-n <br /> ❑ New ® Renewal <br /> Medical Office/Business Name: Channel Medical Center <br /> Medical Office/Business Address 701 E. Channel St <br /> Stockton, CA 95202 <br /> City State Zip Code <br /> Contact Person: Kathleen Marshall <br /> Phone Number: 373-2826 <br /> Storage Facility Name: STERICYCLE <br /> Storage Facility Address: 4135 SWIFT AVE FRESNO, CA 93722 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: STFR CVCLF <br /> Permitted Treatment Facility Address: 119715; yOjTTF RnrK Rn <br /> RANCHO CORDOVA rrp 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: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption an tracking document shall be in employee's possession at all times while transporting medical waste. In addition all copies of <br /> medical waste records sh kept on file at enerator's or health care professional's facility. <br /> Applicant Signature: Date: 12/20/11 <br /> Title: Director Wf- Quality Improvement <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: qO'P� Date: <br /> Expiration Date: Date Paid: I / 3 / I�-Cash or heck : Z 05LM Received By: <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />