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4. <br /> San Joaquin County Public Health Service <br /> Environmental Health Division <br /> Medical Waste Management Program <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 Pfan 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 /> Medical Waste Hauler Information <br /> 0 New M Renewal Ipdi Arial Hospital, LMH Home Health AcgencY, <br /> TtSi Clincis and all LMH eorramnity based events <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: .975- ,S. Fairmont Avenue <br /> City:_ LnAi State: rA Zip Code: 95240 <br /> Contact Person: Donna McCaulev Phone ;t 209 339-7F68 <br /> Storage Facility Name: Lodi PRI? ial Hospital <br /> Storage Facility Address: 975 • airmont Ave. <br /> City: LOM___.___ <br /> State: Zip Code:Ste 95240 <br /> Permitted Treatment Facility Name: <br /> rzcvc e, Inc. <br /> Permitted Treatm nt Facility Address: <br /> City: Rano 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 shalt be in employee's possession at all times while transporting medical waste. In <br /> addition, all copies of medical waste records shall be kept an file at generators or health care prafessicnars facility- <br /> Applicant Signature: <br /> Title: Facilities Coordinator Dace: 12 /15 /2000 <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approva A j Oate: Expiration Date:1Z 3� <br /> EH4502 1043-96 Date Paid i ` / Cash or Cnec< i---Ll 1303 (circle) Acct <br />