COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

° o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton,CA 95205-6232 DEC Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 1 ® 2Q'� APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION AtRMMS AV y 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 .Please complete the information below and mail with$77.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program APPROVFM 1868 E.Hazelton Avenue, Stockton, CA 95205-6232 Q i L Medical Waste Hauler Information ❑ New /Renewal Medical Office/Business Name: TRI—VALLEY HOME HEALTH CARE, INC. Medical Office/Business Address: 37 West Yokuts Ave. Suite C-2 Stockton, CA 95207 City State Zip Code Contact Person: Necita Triguero Phone Number: ( 209) 957-0708 Storage Facility Name: TRI—VALLEY HOME HEALTH CARE, INC. Storage Facility Address: 37 West Yokuts Ave. Suite C-2 Stockton, CA 95207 City State Zip Code Permitted Treatment Facility Name: STERICYCLE PernittedTreatment Facility Address: 1345 Doolittle Drive #C San Leandro, CA 94577-2268 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: Necita Triguero- Title: Registered Nurse 2.Name: Alicia Quibin Title: Registered Nurse 3.Name: Annaliza Santiago Title: Registered Nurse 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 medical ste record hall b e on file at generator's or healthcare professional's facility. UP 'v Applicant Signature: Necita Tricrue R Date: 12/07/2012 Title: Administrator DO NOT WRITE BELOW THIS LINE R.E.H.S.Application Approval: "c� Date: 11 Expiration Date: / 'JI JS -Date Paid: A) / Z Cash or heck : z16 Received By: EHD 45-01 11/19/08