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FROM : TRI VALLEY FAX NO. : 209 957 7866 *pr. 01 2002 03:27PM P2 <br /> San Joaquin County Public He�ilth Sefvic`::s <br /> Environmental Health Division <br /> Medical Waste Managernent Prcg(am <br /> APPLICATION FOR A I+IM€TED QUAN-rlTY HAULING EXEMPTION <br /> to quality fora"Limited Quantity Kauling Exemption"pursuant to the"Medical Waste Management Ac:', the following <br /> cznditions trust be met: <br /> ,rhe generator or health care professional generates less than 20 pounds of medical waste per we 1 , transports less <br /> ne, <br /> than 2Q pounds of medical waste at any one ti <br /> maintains a tracking document pursuant to Chapter 5, and the <br /> generator or parent organix3tion has an tile one of the following: <br /> 1- Medical Waste Management Plan if the generator or parent organ-nation is a large quantity generator 0 a smelt <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- lnfortnatron Document if the generator or parent organization is a small qusnuty generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE coMPLETE THE INFORMATION BELOW AND MAIL WITH 557 1=eE T0: <br /> ,San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> C New 55 Renewal <br /> Medical ofricepjeusiness Name:. TRI VALLEY HOME <br /> ;Medical Ofrica/Business Address #37 West Yokuts Ave- Suite C-2 <br /> City: Stockton State: CA ZpCode:9- -_207 <br /> Contact Person: Necita Tri uero R_N. Adm' Pttorte qr -nznR <br /> Storage Facility Name: TRI VALLEY HOME HEALTH CARE <br /> Storage Facility Address: 37 West Yokuts Ave. Suite C-2 <br /> City: Sto scn State: CA Zip Code: 95207 <br /> Permitted Treatment Fact°sty Marne: Steric cle Medical Waste S ste <br /> Permitted Treatment FaaT:ty Address:11875 White Rock Road <br /> City:®Rancho___CQzd-Q -a Sate: CA Zip Cole: 9 57 4 2. <br /> {ist all employee names acid Wes authofted to transport the medical waste. If not enough space,attach 1001717112d0n. <br /> Dawn Sanders-LVN <br /> 1- Name: Necita Triguero-RN Titre: n-TAT <br /> 2- Name: Letty M riano—RIJ Title:_CoMfnrt- H@j-ar3i -Lx7N <br /> 3- Name:_ Mercur,a Paned- ___ Tide: Arlyn dela Cruz-LVN <br /> Antonieta Maglaki-RN Jmd° th Qs rye-7, J ^ cell Ocuanan-LVN <br /> A copy of this exempddrt and a mcisirig dec=ent si &t5i us errs o Bas gc �tt ® porting m,&,,i waste. In <br /> addition, all copies of me I w=tft records shall be kept an hZe at 9trMrataues or health care prcfeasiamrs tacitly. <br /> Applicant Si nature: �.�c ! <br /> Dace: 04 / OJ-200-1- <br /> Title: - <br /> Do Not Write Below This Line <br /> RE.N.S. rlppiiCacian Approval: !t - Date= 1 � xpiratian Date:._lF �"' <br /> (circle? Acc <br /> Btt;sox :Bas-ss Date Paid /2t /�-t Ol ar Ghedc a s� u <br />