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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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, transport 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 /> 1.Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br /> or a small 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 <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Department APPROVE <br /> Medical Waste Management Program °, <br /> 1868 E. Hazelton Avenue, Stockton, CA 95205-6232 i <br /> Medical Waste Hauler Information <br /> ❑New %6Renewal <br /> Medical Office/Business Name: Hospice of San Joaquin <br /> Medical Office/Business Address: 3888 Pacific Avenue <br /> Stockton CA 95204 <br /> City State Zip Code <br /> Contact Person: Kerrie A Biddle <br /> Phone Number: (209) 957-3888 <br /> Storage Facility Name: Hospice of San Joaquin <br /> Storage Facility Address: 3888 Pacific Avenue <br /> Stockton CA 95204 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle <br /> Permitted Treatment Facility Address: 4135 West Swift Road <br /> Fresno CA 93722 <br /> city-, State -. .. Zip Code_.. <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1.Name: SEE ATTACHED Title: <br /> 2.Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tr` king document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wase records shall be pt o file at nerator's or health care professional's facility. <br /> Applicant Signature: Date: 11/15/2012 <br /> Title: Chief Financial icer ' <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: [_ _44 <br /> - Date: 2/S / 11L <br /> / <br /> Expiration Date: /�/ _Date Paid: 4 / a Cash or ec #: 3 3735 Received By: <br /> EHD 45-01 <br /> i iiivnu <br />