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SAN JOAQUIN COUNTY FILE C <br /> x� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> /Fp N� <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 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> F1 New El Renewal <br /> Arcadia Health Services, Inc. , d/b/a Arcadia Services d/b/a <br /> Medical Office/Business Name: 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.0.N <br /> Phone Number: 415 255-2880 <br /> Storage Facility Name: ���C cs;a 0A."kktnga, �s <br /> Storage Facility Address: (�,�� S� Q, gC 4-&-� Sit-, //Q <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ,,- n C.uCt " ►.tom <br /> Permitted Treatment Facility Address: J!Z s pl!lvr— <br /> `4A0.x L-c.CLr4 Agp CA <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info):C14"� <br /> 1.Name: A1141---(""RN I s <br /> Title: Pivtln RenWA, Kwn-WeA <br /> 2.Name: Ar Title: �3 <br /> 3.Name: j36h4 e k NC's Title: <br /> A copy of this exemption anda tracking docume s 11 be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical records sha a kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 2/27/09 <br /> Title: Sr. Vice President <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: ft Date: 4/v/&V/ <br /> Expiration Date: 12- 131 l 0 l Date Paid: 3 / (p /D'CashCheck#: D0M3 Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />