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Joaquin County Public Health Ses <br /> Environmental Health Division <br /> Medical Waste Management PregraMRCI"$IfLIdiri . 1[EAl-1Il <br /> PD=t,!'T SERVIr,E <br /> APPLICATION FOR A LIMITED QUANTITY HAU L t 1 Z <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 weed, transports less <br /> than 20 pounds of medical waste at any one time, maintains a traciting 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 WiT'ri 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 LN Renewal <br /> Medical Office/Business Name: SAN JOAQUIN COUNTY HEALTH CARE SERVICES DEPARTMENT <br /> Medical OfficelBusiness Address: P- 0. BOX 1499 <br /> FRENCH CAMP, State: CA Zip Code: 95231 <br /> C4.. CHUCK PEEK Phone m(209) 468-6166 <br /> Contact Person: <br /> Storage Facility Name: N/A <br /> Storage Facility Address: <br /> State: Zip Code: <br /> City: <br /> Permitted Treatment Facility Name: SAN JOAQUIN GENERAL HOSPITAL <br /> Permitted Treatment Facility Address: 500 WEST HOSPITAL ROAD <br /> City: FRENCH CAMP State: CA Zip Code: 95231 <br /> List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. <br /> 1- Name: Max Cervantes Title: Housekeeping Service Worker <br /> 2- Name: Jose Lopez Title: <br /> 3- Name: Luis Huante 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, ail copies of medical waste records shag be kep on file at4eneratoees or health care professional's facility. <br /> Applicant Signature: <br /> Title: <br /> Facilities Manager <br /> Date: 12 / 11 / O1 <br /> Do Not Write Below This Line <br /> Q.E.H.S. Application Approval: <br /> Date: /// //oZExpiration Date:/Z/3/ /C)Z' <br /> EH4502 10-03-96 Date Paid l / ! 7 / 0,;', Cash or c?0 (circle) Acct <br />