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SAN JOAQUIN COUNTY • �••:��''•.c ENT _, �•r` 'z RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DEC 2 3 2013 cq l.io �P (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd ��FOR SAN JOAQUIN COUNTY ENVIRONMENTAL APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION HEALTH DEPARTMENT 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. Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department Medical Medical Waste Management Program 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: Gleason House Medical Office/Business Address 423 S . Sari Joaquin St . Stocktorl. Cry 95203 City State Zip Code Contact Person: Qi Coordinator Phone Number: (209) 373-2800 Storage Facility Name: Community Medical Centers , Hammer Storage Facility Address: 721 E. Hammer Lane , Stockton, CA 95210 City State Zip Code Permitted Treatment Facility Name: Stericycle Permitted Treatment Facility Address: 1.1875 White Rock Rd. _-Rancho Cordova , CA 95742 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: Benjamin 'Morrison Title: Ptivsz (-i nn 2. Name: Randy Pinnelli Title: Physician assistant 3. Name: Brandon Michelson Title: Outreach Worker 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 waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: Date: _ C Title: /�'i �- PAYMENT RECEIVED DO NOT WRITE BELOW THIS LINE (( � � 11 DEC 2 3 2013 REHS Application Approval: =L , r1. `A,`,_., Date: Z'1 /0-1/jL SAN JOAQUW COUNTY ENVIRONMENTAL. Expiration Date: /3R /I+Date Paid: 1-:5 Cash or hec :.)-k4g3q Received B�- b HEALTH DEPARTMENT EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION