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an Joaquin County Public Health S'-''dices Environmental Health Divisioh--� Medical Waste Management Program APPLICATION FOP 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 fess 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 I 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- Infofmation Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. 4 PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: PAYMENT San Joaquin County Public Health Services � �� Environmental Health Division JAN 15 1998 Medical Waste Management Program 304 E Weber Ave SAN�64UrN COP e�vylRo�,f��r' Stockton, CA 95202 orvF Medical Waste Hauler Information © Newer Renewal Medical Office/Business Name: Valley IV Services dba Optioncare { Medical Office/Business Address: lanc Road, Stockton State: CA _ TpCode:_ 9521n _ City: (2091 _ Contact Person: TerryHashimoto Pharm D. Pam Car ,en er Phone 0184 Storage Facility Name: 0 tioncare Storage Facility Address: 1016 E. Bianchi Road Suite A-1 I State:_ _Zip Code: City: Stockton Permitted Treatment Facility Name: Steric cle INC. Permitted Treatment Facility Address: 10390 Enterprise r City- Redlands State: CA Zip Code: List all employee names and titles authorized to transport the medical waste.-If not enough space, attach information. 1- Name: Terry Hashimoto Pharm D. Title: C.Pj3pral Man 2- Name: Pam Carpenter RN Title: Administrator 3- Name:_srntt Clinton Pharm Tl- Title: 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 generatoes or health care professional's facility. Applicant Signature: -17a - /ZJ Title: Date: 1 I � I 9� Do Not Write Below This Line Application Approval Date: wf Expiration Date: 13 1 R.E.H.S. App pp ' # 3 EH4502 10-03-96 Date Paid 1 1S/ 90 Cash or Check a27 (circle? Acct f