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SAN JOAQUIN COUNTY EARONMENTAL HEALTH DEPART&T .{} LE a 600 East Main Street, Stockton, CA 95202-3029 \ ops \e � Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s�gov.org/ehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transport 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: 1. 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 snail with $77.00 fee to: San Joaquin County Environmental Health Department 1�•`t Medical Waste Management Program PIFCIVED 600 East Main Street, Stockton, CA 95202-3029 7 2009 Medical Waste Hauler Information SAN 3ON"30IN GOt1N ❑ New M Renewal ENVIFZONME � ,T Medical Office/Business Name: Tri-Valley Home Health Care, Inc. Medical Office/Business Address: 37West Yokuts Avenue, suite - Stockton, CA 95207 City State Zip Code Contact Person: Necita Triguero Phone Number: ( 2 0 9) n957-0708 Storage Facility Name: �, .yAN\t.,1 Ll— e__ �k"klyn GZL, :C;qy. Storage Facility Address: _-ZI y, �Ac, Aug- Vi-F�-. 2. City State Zip Code A&C' Permitted Treatment Facility Name: Permitted Treatment Facility Address: ,_ City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1. Name: Dionicia Calvan Title: RN 2. Name: Dinah Bacolod Title: RN 3. Name: Suzette Torres Title: RN A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies o edical waste records shall be kept on file at generator's or health care professional's facility. Applicant Si ature: ' "" T C Z��-LL Date: Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: ''L /5l / )b Date Paid: 17'l 7 /09 Cash or heck#: 3t Z P Received By: tel. EHD 45-01