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Aoaquin County Public Health Ser. <br /> Environmental Health Division <br /> Medical Waste Management Program DEC <br /> E N V 1 R 01[i,,*.?.,,.- <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERPAIT,/�,- <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, transports 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 /> I- 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 S67 FEE TO: <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 /> C3 New 0 Renewal <br /> Medical Office/Business Name: TRI-VALLEY HOME HEALTH CARE INC. <br /> Address: WEST YOKUTS AVENUE--,—SUITE C-2 <br /> Medical OfficeiBusiness Addre S late: CA _z:lp Code: 95207 <br /> C STOCKTON <br /> City: m:RrWTrjTQMQATnR Phone , 957-0708 <br /> Contact Person:—NECITA TRI [ER0, RN, <br /> Storage Facility Name: TRI-VALLEY HOME HEALTH CARE, _INC. <br /> Storage Facility Address: 37 WEST YOKUTS AVENUESUITE 2 State: CA Zip Code: 95207 <br /> City: STOCKTON <br /> permitted Treatment Facility Name: STERICYCLE ICAL WASTE SYSTEM <br /> Permitted Treatment Facility Address: 11875 WHITE ROCK ROAD State: CA Zip Code: 95742 <br /> City: RANCHO CORDOVA <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Name: NECITA TRIGUERO Title: REGISTERED NURSE <br /> mERCURIA PANED Title: RE)GIEM M NURSE <br /> 2- Name: MARY JONES Title:— <br /> 3- Name: <br /> SEE ATTACHED nt shall be in employee's po=ession at all times while transporting medical waste. in <br /> A copy of this exemption and a tracking document be kept on file at generator's or he2�, ca�professionars facility. <br /> addition, all copies of medical waste records shall <br /> Applicant Signature: Date: 12 / 12 / 02 <br /> ADMINISTRATOR <br /> Do Not Write Below This Line <br /> RILE.H.5. Application Approval- Date:jLjQ/-qExpiration Date:iLL3-1 / <br /> Acct__k., <br /> �Q'Z— Cash or Checl, (circle) <br /> EH4502 10-03-96 Date Paid Cash or Check <br />