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SAN JOAQUIN COUNTY � pgYMENT <br /> ONMENTAL HEALTH DEPART <br /> EI0D I ,`: E I V E D <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 202- <br /> a • Telephone:(209)468-3420 Fax:(209)468-3433 Web: hif <br /> D c 1 2004 <br /> . FOR <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMP'Iq' AQUIN COUNTY <br /> IRONMENTAL <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 $70.00 fee to: <br /> San Joaquin.County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3 Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> F-1 New M Renewal <br /> Medical Office/Business Name: DAMERON HOSPITAL ASSOC'TATTON <br /> Medical Office/Business Address: 525 WEST ACACIA STREET <br /> STOCKTON CA 95203 <br /> City State Zip Code <br /> Contact Person: MARK G. KOENI G <br /> Phone Number: 2094613184 <br /> Storage Facility Name: —same— <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: —same— <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> Lis all eWoe na s an titles authorized to transport the medical waste(If more than 3, attach info): <br /> —Please a��ac�ment- <br /> 1. Name: 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 wa to reco d s all be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12/12/2004 <br /> Title: DIRECTO12 L <br /> DO N T WR BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: I-Zj 1y7%)L/ <br /> Expiration Date: /_SDate Paid: 1A-/L13—/V-T-Cash hec : Received By: �— <br /> EHD 45-02-001 <br /> 10/7/2003 <br />