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/-0 _ o. SAN JOAQUIN COUNTY <br />a� EN)JWNMENTAL HEALTH DEPAR <br />Ouast Main Street, Stockton, CA 95202 0 <br />: . <br />�r �P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd U <br />Filo <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 0117 ting <br />conditions must be met: <br />The generator or health care professional generates less than 20 pounds of medical waste per week, transport less <br />than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 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 <br />or a small quantity generator required to register pursuant to Chapter 4. <br />2. Information Document if the generator or parent organization is a small quantity generator not required <br />to register pursuant to Chapter 4. <br />Please complete the information below and mail with $77.00 fee to: <br />San Joaquin County Environmental Health Department <br />? 565( <br />Medical Waste Management Program <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical <br />Waste Hauler <br />Information <br />�i62 <br />(] New Renewal <br />Medical Office/Business Name: <br />Delta Blood Bank <br />Medical Office/Business Address: <br />Mortri Commierce street <br />Stockton <br />CA <br />95202 <br />City <br />State <br />Zip Code <br />Contact Person: <br />Elayda Podesta <br />Phone Number: <br />943-3830 x220 <br />Storage Facility Name: <br />Delta Blood Bank <br />Storage Facility Address: <br />65 North Commerce Street <br />Stockton <br />CA <br />95202 <br />City <br />State <br />Zip Code <br />Permitted Treatment Facility Name: <br />Stericycle, Inc. <br />Permitted Treatment Facility Address: <br />4135 w. swift Ave. <br />Fresno _ <br />City <br />CT -- <br />State <br />93722 <br />Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />1. Name: SEE ATTACHED Title: <br />2. Name: Title: <br />3. Name: Title: <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: �,, r %d,�S a_, Date: 12--1 - I0 <br />Title: Compliance Offi,6er <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: ��-�-- w4 Date: 12/-/10 <br />Expiration Date: L_/3_/It Date Paid: / � Ab -4&-wh-juCheck #: bi .1-�bL\ Received By: <br />EHD 45-01 <br />