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SAN JOAQUIN COUNTY <br />PAYMENT <br />, <br />EORONMENTAL HEALTH DEPARI&T b - r= E)� <br />600 East Main Street, Stockton, CA 95202-3029 f .° r �'� <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov. <br />s ?,- �N JOAQUIN COUNTY <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONIRONMENTAL. <br />HEALTH DEPARTMENT <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 $77.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical Waste Hauler Information <br />❑ New ['A Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address: <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />SAN JOAQUIN COUNTY HEALTH CARE SERVICES DEPT. <br />P.O. BOX 1499/500 WEST HOSPITAL ROAD <br />FRENCH CAMP, CA. 95201 <br />City <br />State <br />DENNIS GORTON OR GEORGE MUSE <br />(209) 468-6998 OR (209) 468-7397 <br />�a <br />City <br />State <br />Permitted Treatment Facility Name: SAN JOAQUIN GENERAL HOSPITAL <br />Permitted Treatment Facility Address: 300 WRST HOSPITAL <br />Zip Code <br />Zip Code <br />FRENCH CAMP, CA. 95231 <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 />SUSAN RAMIREZ ASSISTA HOUSEKEEPING MANAGER <br />1. Name: THANE TRACEWELL Title: HOUSEKEEPING SERVICE WORKER <br />2. Name: ZACK HERNANDEZ Title: HOUSEKEEPING SERVICE WORKER <br />3. Name: JAVIAR CHAVEZ Title: HOUSEKEEPING SERVICE WORKER <br />ANDY RAYA HOUSEKEEPING SERVICE WORKER <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 <br />,lrecords shall be kept on fo at generator's or health care professional's facility. <br />Applicant Signature: <br />Title: -- A, <br />Date: / <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: _ Date: 0/ <br />Expiration Date: [ / / Date Paid: �/ / Check 2 `°�. Received By: <br />EHD 45-01 <br />