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PgUlly\ <br /> SAN JOAQUIN COUNTY <br /> {� EN40NMENTAL HEALTH DEPART4T <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520%27 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: sjgov g/ ! <br /> [.)E C 14 2004 <br /> APPLICATION FOR A LIMITED QUANTITY HAULI G 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 <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> p New ® Renewal <br /> Medical Office/Business Name: Doctors Hospital of Manteca <br /> Medical Office/Business Address: 1205 E. North Street <br /> Manteca, CA 95336 <br /> City State Zip Code <br /> Contact Person: Carmen Silva CNO/COO <br /> Phone Number: 209-239-8361 <br /> Storage Facility Name: Doctors Hospital of Manteca <br /> Storage Facility Address: 1205 E. North Street <br /> Manteca, CA 99336 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle, Inc. <br /> Permitted Treatment Facility Address: 4135 W_ Swift Avi- <br /> Fresno rA 93722 <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: Jeremy McIlvain Title: Director, Environmental Svcs <br /> 2. Name: Geri Quinn Title: AM Lead/Housekeeper <br /> 3. Name: Sherry Hack Title: PM Lead/Housekeeper <br /> see attached for additional names) <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 wa records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: G - Date: 11 /30/04 <br /> Title: —Chi pf FXPcutiunClfficPr <br /> DO N T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval Date:If <br /> Expiration Date: Date Paid: _�/ tS�'/ Cash or Check#: L( 5 (q Received By: - <br /> EHD 45-02-001 <br /> 10/7/2003 <br />