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Donna McCauley <br /> Facilities Management .,ounty Public Health Service_ <br /> imental Health Division <br /> 3ste Management Program <br /> Lodi 975 South Fairmont Avenue <br /> Memorial Lodi, California 95240 AITED QUANTITY HAULING EXEMPTION <br /> (209)339-7668 <br /> Hospital Fax (209) 339-7672 <br /> ;ion" pursuant to the "Medical Waste Management Act", the following <br /> 1 ne generator-ar Rearm-care proressiunai geriutates 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 small <br /> 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 S67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> XX Medical Waste Hauler Information <br /> New dJ Renewal <br /> Lodi Memorial Hospital, INH Hcane Health Agency, <br /> Medical Office/Business Name: IM Clinics and all INH ccmmmi.ty based events <br /> Medical Office/Business Address: 9 75 5. ntnCritt <br /> City: Lodi State: CA Zip Code: 5240 <br /> Contact Person: Donna McCa ey Phone ;�: 209 339-7668 <br /> Storage Facility Name: Dodi Memorial Hospital <br /> Storage Facility Address: 575 S. Faixwnt Ave. <br /> City: Lodi_ State: CA Zip Code: <br /> Permitted Treatment Facility Name: BFI <br /> Permitted Treatment Facility Address: 3326 Fitzgerald-- <br /> City: Rancho Cordova State: CA Zip Cade: 95742 <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: See Attached Title: <br /> 2- Name: Title: <br /> 3- Name: Title: <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 file at generator's or health care professional's facility. <br /> Applicant Signature: �'}til2,acr C <br /> Title: Facilities ator Date: 12 / 13 /99 <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date:&,!?-Z�f2 Expiration Date:/2/.3/ I ZL2'aO <br /> EH4502 10-03 96 Date Paid / / / Cash or Check T�y� 7 a(circle) Acct_41— — <br />