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SAN JOAQUIN COUNTY <br /> MEIT <br /> ?, ENVIRONMENTAL HEALTH DEPART <br /> 304 East Weber Avenue, P Floor,Stockton,CA 95202-2708 <br /> (209)468-3420•Fax:(209)468-3433 - Web:www.co.san joaquin.ca.us/ehd <br /> `' aR <br /> APPLICATION FOR A LINIITED QUANTITY HAULING EXEMPTION <br /> Touali for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following <br /> q fY <br /> conditions must be met: <br /> The generator or health care professional generates la s than 20 pounds of medical ntains a tracking document pursuantto Chapter transport <br /> the ss <br /> than 20 pounds of medical waste at any one time,m <br /> generator or parent organization has on file one of the following: g q generator <br /> 1. Medical Waste Management Plan if the ogenera or ur pant to rganizChaptrti n is a lar a uantity g <br /> or a small quantity generator required gi p generator not required <br /> 2. Information Document if the generator or parent organization is a small quantity g <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$70.00 fee to: , <br /> San Joaquin.County En-,-ironmental Health Department <br /> Medical Waste Management ProgramStockton,CA 95202 <br /> 304 East Weber Avenue, 3`d Floor, <br /> Medical Waste Hauler Information <br /> E]New Renewal <br /> Medical OfficeBusiness Name: DAMERON HOSPITAL ASSOCIATION <br /> Medical office/Business Address: 525 WEST ACACIA STREET <br /> STOCKTON CA 95203-2484 Zip Code <br /> City State <br /> MARK G. KOENIG, MS, CHSP <br /> Contact Person: 20946131 <br /> Phone Number: <br /> Storage Facility Name: <br /> —same— <br /> Storage Facility Address: <br /> • State Zip Code <br /> City <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Treatment Facility Address: <br /> City <br /> State Zip Code <br /> List all emplo ee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> * see attached listing Title: <br /> 1.Name: Title: <br /> 2.Name: Title: <br /> 3.Name: <br /> A copy of this exemption and a tracking doc ent shall be f le at�generator's or health care professionalmployee's possession at all times while 's facilityng medicalwa'te. In <br /> 1 <br /> addition,all copies of medical wa ere or 12/24/2003 <br /> Date: <br /> Applicant Signature: <br /> Title: MARK G. KOENIG DIRECTO RMS <br /> DO N T WRI BELOW `THIS LINE Date: <br /> R.E.H.S. Application Approval: +� Received By: <br /> / 1 p Date Paid: Cash or eck <br /> Expiration Date: ,ter <br />