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Joaquin County Public Health Soes <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracdng 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 or a small <br /> 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 to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH Sbr7 FEE TO: <br /> San Joaquin County Public Health Services -- <br /> Environmental Health Division Medical Waste Management Program r4l �., <br /> 304 E Weber Ave ° <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> C1 New (K Renewal <br /> Medical office/Business Name:. TRI-VALLEY HOME HEALTH CARE INC. <br /> Medical Office/Business Address: 37 WEST YOKUTS AVENUE SUITE C2 Zp Cade: 95207 <br /> City: STOCKTON S tate: <br /> Contact Person: NECITA T. TRIGUERO Phone (209) 957-0708 <br /> Storage Facility Name: TRI-VALLEY HOME HEALTH CARE NC <br /> Storage Facility Address: 37 WEST YOKUTS AVENUE SUITE C2 State: CA Zip Code: 95207 <br /> City: STOCKTON <br /> Permitted Treatment Facility Name: STERICYCLE MEDICAL WASTE SYSTEM <br /> Permitted Treatment Facility Address: 11875 WHITE ROCK ROADState: CA Zip Code: 95742 <br /> City: RANCHO CORDOVA <br /> port the medical wase. If not enough space, attach information. <br /> List all employee names and titles authorized to trans <br /> NECITA TRIGUERO-RN 4. Title: MARIA BAUTISTA-LVN <br /> 1- Name: Title: EPERANZA AGATEP-LVN <br /> 2- Name: ALTCTA O(ITBTN r VN 5. Title: DULLA DOCDOR-LVN <br /> 3- Name: F Tr ARFTH 'RTTS-SELT.—IM`T 6. <br /> 8. ERLINDA ARTELLAN-LVN 9. ANNA LI ZA BONGCARON-LVL <br /> 7. COMFORT 1�IATADI-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 medical waste records shall be kept on fife at generator's or health care ionars fa itY- <br /> Applicant Signature: �C%� <br /> 7- l ;'Zt <br /> Title: ADMINISTRA R Date: <br /> Do Not Write Below This.Line <br /> Date: Expiration Date: <br /> R.E.H.S. Application Approval: <br /> / / 713 lb <br /> EH4502 10-03-96 Date Paid -/ /1n/ Cash o eC< _a4c�L(circle) Acct <br />