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SAN JOAQUIN COUNTY / E f i� <br /> `� � <br /> ( EI KONMENTAL HEALTH DEPARTMENT RE-C IVF-E) <br /> { <br /> TF. . 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 , <br /> a � � <br /> Telephone: 209 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd G t(' 2 2006 <br /> Ci�aR� <br /> SAht Jti'IQJlr�l CCUsi",�y <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPWRQNMENrAL <br /> 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$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: / Lawrence Family Center& Clinic <br /> Medical Office/Business Address: 721 Calaveras Street <br /> Lodi CA 95240 <br /> city State Zip Code <br /> Contact Person: Terrie P. Mabalon R.N. <br /> Phone Number: 209-373-2860 <br /> Storage Facility Name: Woodbridge Medical Group (WMGZ� _ <br /> Storage Facility Address: 2401 West Turner Road Suite#450 <br /> Lodi CA 95242-2185 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Steric c�le <br /> Permitted Treatment Facility Address: 11875 White Rock Road <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: Robin Kruger Title: R.N./Clinic Manager <br /> 2. Name: Maria Garza Title: Medical Receptionist <br /> 3. Name: Tai Tran Title: Physician Assistant <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 records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: 00m • P1JV Date: 12/12/2006 <br /> Title: Terrie Mabalon Re istered Nurse <br /> DO NPT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: r Date: j j j <br /> Expiration Date: ../?,--/ ?/ /Date Paid: A2 Check#: L�01 q Received By: <br /> EHD 45-01 <br />