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Jan Joaquin uounLy ruutiu nt:4iu i -jul viv;-.4 �edical Environmental Health Division Waste Management Prcgra APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemptiofy, pursuant to the"Medical Waste Management Act", the following =editions must be met The generator or health care professional generates less than 20 pounds of medical waste per we--K twspions less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information C2 New 0 Renewal CARE CALLS HOME HEALTH, INC. , DBA Medical Office/Business Name: DIVINITY HOME CARE OF CENTRAL VALLEX Medical Office/Business Address: 1803 W March La Suite C Stockton CA City: Stockton State: CA_Zip Code: 95207 Contact Person:- Vivian Roderick Phone 14r, 209-475-6s3o Storage Facility Name: INTEGRATED ENVIRONMENTAL SYSTEMS_ Storage Facility Address: 499 High St. Zip Code:City: Oakland State: G Permitted Treatment Facility Name: -.qMp -AP- AhQ17-P- Permitted Treatment Facility Address: State: Zip Code: City: List ail employee names and titles authorized to transport the medical waste. If not enough space, attach information. I- Name: zaQ @t;t;;;94eEj list Title. 2- Name: Title: 3- Name: Title. A copy of this exemption and atracking document shall be in employee's possession 2talitimes whsle tray parting medical waste' In addition, all copies of medical waste records stied be kept on me at generator's or health care professional's facility. Applicant Signature: Date: Title: Do Not Write Below This Line IQ - AL--L LE.H.S. Application Approval: WAAnlfkA _Date: 11 (Expiration Date.- ILL /D k—) 1-e h or Chedc :1 (circle) Accr____--.�-. EH4502 10-03-96 Date Paid Cas r