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AQu/N SAN JOAQUIN COUNTY 10 RAREM ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 7 2011 N { 600 East Main Street, Stockton, CA 95202-3029 .. •. - `. reeENVIRONMENT HEALTH (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd C;-. _ _,.•..•P PERMIT/SERVICES APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports 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 1 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 M Renewal Medical Office/Business Name: Arcadia Health Services, Inc DBA Arcadia Home Care & Staffin 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 Hump Carp & Staffing Storage Facility Address: 1375 Sutter Street, Ste. 110 San Francisco, CA 94109 City State Zip Code Permitted Treatment Facility Name: Stericycle, Inc Permitted Tranfmanf Fanility AririrPcc: 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: Jeff Zimmerman Title: RN 2. Name: Sharon Rob son Title: RN 3. Name: Lindsey Brbdk Title: RN A copy of this exemptioand tracking ument shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records all pt on at generator's or health care professional's facility. Applicant Signature: Date: 12-22-11 Title: Executive Vice P e ident "D1O,._NOT WRITE BELOW THIS LINE REHS Application Approval: <?,t .� � L-� Date: Expiration Date: /3 /�Z Date Paid: �Z/Z l / Cash or Received By: _ EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION