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t -� 0SAN JOAQUIN COUNTY <br /> �r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> � 1�o �` <br /> APPLICATION FOR A LIMITED QUANTITY HAULING 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$72.00 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 /> ❑New ® Renewal <br /> Medical Office/Business Name: DAMERON HOSPITAL ASSOCIATION <br /> Medical Office/Business Address: 525 WEST ACACIA STREET <br /> STOCKTON CA 95203 <br /> City State Zip Code <br /> Contact Person: MARK G. KOENIG <br /> Phone Number: 2094613184 <br /> Storage Facility Name: —same— <br /> Storage <br /> 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 /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): please s e e <br /> 1. Name: Title: attachment <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking doe ent shall a in e p eels possession at all times while transporting medical waste. In <br /> addition,all copies of medical w to r orris all be k on fi e t e r o ealth care professional's facility. <br /> I <br /> Applicant Signature: Date: 12/15/2006 <br /> Title: MARK G. KOENIG, DIRECTOR LRM <br /> DO N T WRITE BELOW HIS LINE <br /> R.E.H.S. Application Approval: cam- Date:) Z /Zei <br /> Expiration Date: /Z /3/ / Date Paid: / U 49asli-ea Check#: l,3 3 Received By: <br /> EHD 45-01 <br /> 07/31/06 <br />