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SAN JOAQUIN COUNTY <br /> YI <br /> two = ENSONMENTAL HEALTH DEPARTAT <br /> RECEIVED <br /> .. 600 East Main Street, Stockton, CA 95202-3029 <br /> �c c� Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd DEC 2 3 2009 <br /> r� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI( JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <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 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New M Renewal <br /> Arcadia Health Services, Inc. DBA Arcadia Services <br /> Medical Office/Business Name: DBA Arcadia Health Care <br /> Medical Office/Business Address: 1375 Sutter Street, Ste 110 <br /> San Francisco, CA 94109 <br /> City State Zip Code <br /> Contact Person: Judy Howard, D.O.N. <br /> Phone Number: 415-255-2880 <br /> Storage Facility Name: Arcadia Health Care Service <br /> Storage Facility Address: 1375 Sutter Street, Ste 110 <br /> San Francisco, CA 94109 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle, Inc. <br /> Permitted Treatment Facility Address: 1345 Doolittle Drive <br /> San Leandro, CA 94577 <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: Brenda Ogilvie Title: RN <br /> 2. Name: Janet Danno Title: RN <br /> 3. Name: Ruth Penna Title: RN <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies Lofmedical waste recor�shallbe kept on fi at generator's or health care professional's facility. <br /> Applicant Sign f Date: 12/17/09 <br /> Title: Contract_ Spec'alist II <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: 1% /111)A�q <br /> Expiration Date: A / 3 1 �� Date Paid: Q' Cash or Check • b5 Received By: <br /> EHD 45-01 /in <br />