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�oG SAN JOAQUIN l 0UN"I-Y �a c o EN*NMENTAL HEALTH DEPARTM ffCIV EI�/ED ENT 600 East Main Street, Stockton, CA 95202-3029 �c ;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj v. e OEC 10 2009 of APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONAN JOAQUIN cOUNTY H�Ep,NVI OO�NpME T AL t"" t AENT To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac , te o11 owing 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 reB ed to register pursuant to Chapter 4. nECp V E Please complete the information below and mail with $77.00 fee to: DEC 1 0 2009 San Joaquin County Environmental Health Department Medical Waste Management Program ENVIRONMENT HEALTH 600 East Main Street, Stockton, CA 95202-3029 PERMIT/SERVICES Medical Waste Hauler Information ❑ New Renewal Medical OfficeBusiness Name: Delta Blood Bank Medical Office/Business Address: 65 north Commerce Street Stockton CA City State Zip Code Contact Person: Elavda nodesta Phone Number: (209) 943•-3830 ext. 220 Storage Facility Name: Delta Blood Bank Storage Facility Address: 65 North Commerce Street Stockton CA 9522 City State Zip Code Permitted Treatment Facility Name: Stericvcle, Inc. Permitted Treatment Facility Address: 4135 W. Swift Ave. Fresno CA City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: SEE ATTACHED Title: 2. Name: Title: 3. Name: 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 generator's or health care professional's facility. Applicant Signature: _ to ��odx�--• Date: 12 e-o� Title: Compliance Officer DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: �1—�:..C- Date: Expiration Date: 11- /1b Date Paid: \ 1—/ \t% / 05 Cash o heck Received By: EHD 45-01