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SAN JOAQUIN COUNTY s <br /> /r ' ` NV .0}NMENTAL HEALTH DEPARTMJ f 1 <br /> i. 600 East Main Street, Stockton, CA 95202-3029 <br /> 1•'' <br /> ILE COPY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 T3'eb: vnv`�.slgov.org/ I <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION k <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. I <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 DepartmentPAYMENT <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 DEC 2 0 2010 <br /> sAN oA4urN cuuy <br /> Medical Waste Hauler Information � .ti,� <br /> eALTH 0�-:4�or,� <br /> ❑ New I Renewal <br /> Medical OfficelBusiness Name: Lawrence Family Center & Clinic <br /> Medical Office/Business Address: 721 Calaveras St. <br /> Lodi, CA 95240 <br /> City State Zip Code <br /> Contact Person: Kathleen Marshall <br /> Phone Number: 209 373-2826 <br /> Storage Facility Name: Woodbridge Medical Group <br /> Storage Facility Address: 2401 W. Turner Rd. # 450 <br /> Lodi CA 95242--2185 <br /> City State Zip Code <br /> Permitted Treatment Facility Nannie: S er'c cle <br /> Permitted Treatment Facility Address: 11875 White Rock Rd. <br /> Rancho Cordova CA 95742 <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 /> 1. Name: Maria Barron Title: lead Receptionist <br /> 2. Name: Diane Baba co Title: Clinic Manager <br /> 3. Name: Livvy Jackson Title: Registered Nurse <br /> A copy of this exemption and a tr eking document shall be in employee's possession ac all times while transporting medical Nraste. In <br /> addition,all copies of medical�4 to records shall <br /> be kept on file at generator's or health care-professional's facility. <br /> Applicant Signature: + r Date: 12/16/10 <br /> Title: f 'alit <br /> Improvement <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: OU <br /> Expiration Date: Date Paid: Id-I d-O l l U Cash orheck . GAO /(a T Received By: 1-6 <br /> EHD 4S-ol <br />