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�04�`�`'In•.co SAN JOAQUIN COUNTY <br /> 4 ENOONMENTAL HEALTH DEPARTIT <br /> H � <br /> 304 East Weber Avenue, 3r'Floor, Stockton, CA 95202-2708 <br /> P (209)468-3420•Fax:(209)468-3433 • FVeb:www.co.san-joaquin.ca.us/ehd <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$70.00 fee to: <br /> San Joaquin County Environmental Health Department [ J <br /> Medical Waste Management Program �•./ U <br /> 304 East Weber Avenue, Yd Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New RkRenewal <br /> Lodi Memorial Hospital, LN:H Home Health Agency, <br /> Medical OffieeBusinessName: LMH Clinics and all LMH Community hased artivitiPc & event. <br /> Medical Office/Business Address: 975 S. Fairmont Avenue <br /> Lodi, CA 95240 <br /> City State Zip Code <br /> Contact Person: Donna McCauley <br /> Phone Number: 209-339-7668 <br /> Storage Facility Name: Lodi Memorial Hospital <br /> Storage Facility Address: 975 S Fairmont Ate <br /> Lodi CA 95240 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle, Inc. <br /> Permitted Treatment Facility Address: 3326 Fitzneral� <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: 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 21 generator's or health care professional's facility. <br /> Applicant S at re: C <br /> Cr Date: <br /> Title: �--' <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _��� Date: <br /> Expiration Date: �/ l b` Date Paid: l_�l /1 Cash or Check#: /,tom�- Received By: K- <br /> LI ID 45.02-001 <br />