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�qu1y o r SAN JOAQUIN COUNTY ENV ONMENTAL HEALTH DEPARTM 1T 304 East Weber Avenue,3rd Floor, Stockton, CA 95202-2708 c . no.P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd S9�'IG 2(j(j APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTICa i c "UM Nfi�pfi dT�C To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", the f0Y�12�Svti g conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport 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$72.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 Medical Waste Hauler Information ❑New ® Renewal Medical Office/Business Name: King Familv Center Medical Office/Business Address: 2460 East Lafayette St Stockton CA 95202 City State Zip Code Contact Person: Terrie P. Mabalon R.N. Phone Number: 209-373-2860 Storage Facility Name: Channel Medical Center Storage Facility Address: 701 E. Channel Street Stockton CA 95202 City State Zip Code Permitted Treatment Facility Name: Stericycle Permitted Treatment Facility Address: 11875 White Rock Road 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: Melissa Goralka Title: PAC/DSD 2. Name: Virginia Valdez Title: Registered Nurse/CPSP 3. Name: Vicky Segura Title: Medical Assistant/CPSP 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: f —Date: 12/12/2006 Title: Terrie Mabalon Registered Nurse DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: QL -- Date: /Z/�Expiration Date:_t-Z—/_3L/_D-7-Dat \2-Date Paid: � O�, Gash-or Check#: ��{0� Received By: EHD 45-01 07/31/06