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Sa*Environmental quin County Public Health Se I ,,ih� h ' r , ,, t:tti11EALIII Health Division .,,- �D,,f!(,;- Medical Waste Management Program 03 OCT -7 AM 11: 57 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac;', the following conditions must be met The generator or health care professional generates less than 20 pounds of medical waste per week, transports less ,han 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 organizagion 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''3pFEE TO: PAYMENT San Joaquin County RECEIVED Environmental Health OCT 7 203 Medical Waste Management Program 304 E Weber Ave SAN JOAQUIN COUNTY Stockton, CA 95202 � PUBLIC HEALTH SERVICES [6 ENVIRONMENTAL HEALTH DIVISION Mddi'dil WaS4 F(Auler Inform on ® New ❑ Renewal Medical Office/Business Name:. Rehahvocus Home Health, Inc. Medical Office/Business Address: 1 313 W. Robinhood nr. , Suite A-4 City: Stockton State: CA ZIP Code:95207 Contact Person: navid Raposa Phone T 472-7005 Storage Facility Name: SAA Storage Facility Address: City: State: Zip Code: Permitted Treatment Facility Name: n/a Permitted Treatment Facility Address: City: State: Zip Cade: List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: Cheri Newcomb, RN Title: nn(,S 2- Name: Torrey Staritner, RN Title: Nursing Supervisor 3- Name: Title: 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 to records shad be kept on file at generator's or health cans professional's facility. Applicant Signature: Title: Administrator Date: 10 / 03 / 03 9u)OPI1,71 F666 jj,? 7l N t 45 �n�✓ �rlPt�� Do Not Write Below This Line It.E.H.S. Application Approval: Date: / / Expiration Date: EH4502 1003-96 Date Paid ( / 2 / Cash heck `N0(circle) Acct__