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�o. Qu I" coG JOAQUIN COUNTYW <br /> �'� PAYMENT <br /> a a ME <br /> N { E ONMENTAL HEALTH DEPRECEIVED <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9 <br /> P.. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd DEC l 6 2004 <br /> �AC�FOR�� OAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI� TH O ARTM L <br /> HEALTo 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 $70.00 fee to: <br /> San Joaquin County Environmental Health Department i <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: - <br /> Medical Office/Business Address: 37 WEST YOKUTS AVENUE,SUITE C2 - <br /> STOCKTON, CA 95207 <br /> City State Zip Code <br /> Contact Person: NECITA TRIGUERO <br /> Phone Number: ( 209 ) 957-0708 <br /> Storage Facility Name: TRI VALLEY HOME HEALTH CARE INC <br /> Storage Facility Address: 37 WEST YOKUTS AVENUE Si1TTF c'2 <br /> ST CKT CA 95207 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: STERICYCLE MFT�TC'AT WASTE SVSTFM <br /> Permitted Treatment Facility Address: 11875 WHITE ROCK ROLA AD 95742 <br /> RANCHO State Zip Code <br /> City <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1.Name: NECITA TRIGUERO—RN —5. Title: MARIA BAUTIST.A—LVN <br /> 2.Name: ELIZABETH RUSSELL—RN 6 . Title: COMFORT MATADI—LVN <br /> 3. Name: BESSIE SAITON—LVN 7 . Title: ALICE QIJTRTN—RN <br /> 4.NAME .ARVIN YADAO—LVN <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 Inedical waste records shall be kept on file at generator's or health care professional's facili <br /> Applicant ature: -e� 1 � Date: <br /> Title: �S <br /> DO NO WRI E ELOW THIS LINE <br /> Application Approval: Date: 1'L/ z /wo <br /> R.E.H.S pp PP <br /> �,�Date O� / / heck# 5 2 Received By: _ <br /> Expiration Date:�/�/_,L Paid:�� Cash or-� <br /> EHD 45-02-001 <br /> 10n12003 <br />