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SAN JOAQUIN COUNTY <br /> ENOONMENTAL HEALTH DEPARTOT <br /> 600 East Main Street, Stockton, CA 95202-3029 FILE C <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web:www.sjgov.org/ehd <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 $77.00 fee to: <br /> San Joaquin Countv En ironmental Health Department <br /> Medical Was,-,.... ,_ c Pro ram PAyMlZNT <br /> 600 East Main Street, St ..on, C., "` 202-3029 <br /> Ll�� <br /> Medical Waste Haub_ .Y ;< = u 1 2 100 <br /> SqN,/QAQUIN C <br /> ❑ New ❑ Renewal HEALTH p PAS MSN ry <br /> Medical Office/Business Name: Tri-Valley Home Health Care Inc. T <br /> Medical Office/Business Address: #37 West Yokuts Suite C-2 <br /> Stockton, CA 95207 <br /> City State Zip Code <br /> Contact Person: Necita T. Triguero <br /> Phone Number: ( 2 0 9) 957-0708 <br /> Storage Facility Name: Tri-Valley Home Health Care Inc. <br /> Storage Facility Address: #37 West Yokuts Suite C-2 <br /> Stockton, CA 95207 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle Inc. <br /> Permitted Treatment Facility Address: 4135 West Swift Avenue <br /> Fresno CA 93722 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): <br /> 1. Name: Necita Triguero Title: RN <br /> 2. Name: Alicia nuibin Title: RN <br /> 3. Name: Melchor Tupas Title: RN <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall be kept on file atgenerator's or health care professional's facility. <br /> Applicant Signature: _r '� ate: <br /> Title: Agency Admini tratox' ` <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: t 7_ Date Paid: 12- /D$' Cash o§ec <br /> • -2-77-7 Received By: <br /> EHD 45-01 <br />