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z I- •quin County Public Health S 'cc� nvlronmental Health Division Medical Waste Management Program 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- Medica! 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 $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division O Medical Waste Management Program P.O. Box 388 Stockton, CA 95201-0388 Medical Waste Hauler Information C] New 21 Renewal Medical Office/Business Name: Valle,L IV Services dha Qptioncnre _ Medical Office/Business Address: 1016 E Bianchi_ Road #A-1 City: Stockton State. Zip Code: .952io" Contact Person: Terr .. 13ashimo o Phone #7 (2o2) AZ2-ois4 Storage Facility Name: 0 tioncare Storage Facility Address: 1016 E. Bianchi Rd. Suite A-1 City: Stockton State: CA Zip Code: 95210 Permitted Treatment Facility Name: Steric cle INC. Permitted Treatment Facility Address: 10390 Enterprise City: Redlands State: CA Zap Code: 92374 E List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. 1- Name: Terr Hashimoto Pharm D Title: Director of Pharmacy 2- Name: Chrystine Martin RN_ Title: Director of Nursing 3- Name: Pam Carpenter RN Title: Administrator A copy of this exemption and a tracking document shall be in employee's possession at ail times while transporting medical waste. In addition, all copies of medical waste records shall be kept an file at generator's or health care professional's facility- Applicant Signature:_ Title: Date: 03 / 13 197 Do Not Write Below This Line R.E.H.S. Application Approval: Date: I I_22Mpiration Date: I 1 EH4502 10-03-96 Date Paid _ 3 1J -_lam Cashor ec (circle) Acct