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SAN JOAQUIN COUNTY PIE ONMENTAL HEALTH DEPARTM* 600 East Main Street, Stockton, CA 95202-3029 c,? � Telephone: (209)468-3420 Fax:(209)468-3433 Web: www.sigov.org/ehd 2 ,9 2010 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION4 oAQU1N you NV HEALTH UNMENTq� To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", �E9,6i;;ng conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transport 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: San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton,CA 95202-3029 Medical Waste Hauler Information ❑ New ® Renewal Arcadia Health Services, Inc DBA Arcadia Services DBA Medical Office/Business Name: Arcadia Health Care Medical Office/Business Address: 1375 Sutter Street, Ste. 110 San Francisco, CA 94109 City State Zip Code Contact Person: Judy Howard D.O.N. Phone Number: 415-255-2880 Storage Facility Name: Arcadia Health Care Service Storage Facility Address: 1375 Sutter Street, Ste. 110 San Francisco CA 94109 City State Zip Code Permitted Treatment Facility Name: Stericycle, Inc. Permitted Treatment Facility Address: 1345 Doolittle Drive San Leandro, CA 94577 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): 1. Name: r,> (L.0 -e,- Title: Z 2. Name: l-e nLti Title: 1Z-At 3. Name: F C)C14S Title: 1ZA A copy of this exemption and a tracking d current shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical /1te r(Aods hall be keV n file t generator's or health care professional's facility. Applicant Signature: C� il �-� Date: 12-15-1 o Title: Director of Compliance DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: ..��\.),.mss Date: Expiration Date: Date Paid:X_?.- /1_ 10 C Check#: Received By: _ EHD 45-01