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oPgu"� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT wA...... __.:_-X '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd �jFOR APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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, transports 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 complete the information below and mail with $77.00 fee to: 777a San Joaquin County Environmental Health DepartmentAPpR®``j � PAYMENT Medical Waste Management Program I L RECEIVED 1868 East Hazelton Avenue, Stockton, CA 95205-6232 FEB 10 2014 Medical Waste Hauler Information SAN JOAQUIN COUNTY ENVIROMENTAL ❑ New IN Renewal HEALTH DEPARTMENT Medical Office/Business Name: TRI-VALLEY HOME HEALTH CARE, INC. Medical Office/Business Address 37 West Yokuts Ave. Suite C-2 oc ton, CA 95207 City State Zip Code Contact Person: Necita T. Triguero Phone Number: 957-0708 Storage Facility Name: TRI-VALLEY HOME HEALTH CARE, INC. Storage Facility Address: 31 West Yokuts Ave. Suite C-2 207 City Stockton State Zip Code Permitted Treatment Facility Name: STE.RICYCLE Permitted Treatment Facility Address: Doolittle Drive #C San Leabdro, 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: Emma Adam 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 of medical waste records s all be pt on fil""�t,ge erator's or It care professional's facility. (. �" J ` Vii Applicant Signature. N cita T. Trigue , RN Date: 02/05/2014 Title: Administrator DO NOT WRITE BELOW THIS LINE REHS Application Approval: Date: •�: /�/ Expiration Date: I'L/�/�Date Paid: / 10/ A Cash or,-Check 01 �D�0 Received By: EHD 45-01512/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION