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t 7t <br /> Y . San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management .Program <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, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 5, 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 or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Information Document,if'the."generator orf"parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4 _ <br /> -. <br /> PLEASE COMPLETE THE INFORM_ ATION BELOW AND MAIL WITH 567 FEE To:".". ; 3 <br /> -,'�' y. e� .ea R1^� -MAI' 'E•3' -j <br /> San Joaquin County Public Health Servi6e's` <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> Medical Waste Hauler Information <br /> 0 New 1 Renewal ' <br /> Medical Office/Business Name: Valley IV Services dba Optionc,are <br /> Medical Office/Business Address: 1016 E. Bianchi Road, #A-1 <br /> City: Stockton State: CA Zip Code:_95210 <br /> Contact Person: Terry�Hashimoto. Pharin D Chrystine.Martin RN Phone#: (9.oc)) 472—oig4 <br /> Storage Facility Name: Option_care _ <br /> Storage Facility Address: 1016 E. Bianchi Rd. Suite A-1 <br /> City: Stockton State: CA Zip Code: 95210 <br /> Permitted Treatment Facility Name:. Stericycle, _ INC. ____ j <br /> "��.��Periiiitfed Treatrri`ent-Facility Address: .10390 :Enter rise • r - - '�-� .J <br /> �• �G€fy:=��'Redlaiida - ;}� .State: GA Zip Cade: 92374' - ; <br /> r List allemployee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> I- Name: Terry Hashimoto Pharm DTitle: Director of Pharmacy_ <br /> 2- Name: Chrystine Martin RN T Title: Director of Nursing <br /> 3- Name:_ Pam Carpenter RN Title: Administrator <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 of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: �C+ 7 <br /> Title: ��-ucsr ol� tJ uar Date: 03 / 13 97 <br /> . Do Not.Write Below This Line <br /> R.E.H.5, Application Approval: ©ate: / Expiration Date: <br /> -�sn: 107 )3-0� Date °aia Cash or Che(--',< = circle) .acct <br />