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SAN JOAQUIN COUNTY <br /> EN HEALTH DEPARTM�T ,ems <br /> { 95202-] SPY <br /> 600 East Main Street, Stockton, CA 0 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd <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 following <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: CO24 -1 It <br /> San Joaquin County Environmental Health Department Ag-OD379,37 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ®New ❑ Renewal <br /> Medical Office/Business Name: Gleason House <br /> Medical Office/Business Address: 423 S. San Joaquin St. <br /> Stockton, CA 95203 <br /> City State Zip Code <br /> Contact Person: Kathleen Marshall <br /> Phone Number: (209) 373-2826 <br /> Storage Facility Name: Hammer <br /> Storage Facility Address: 1721 E. Hammer Lane Suite A <br /> Stockton, CA 95210 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle <br /> Permitted Treatment Facility Address: 11875 White Rock Rd. <br /> Rancho Cordova CA 95742 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more,than 3, attach info): <br /> 1. Name: Jonalyn Vergara Title: Clerical Assistant <br /> 2. Name: Diane Fountain Title: Case Manager <br /> 3. Name: Angie Segura Title: Medical Assistant <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 ste records shall be kept on file at generator's or health care professional's facility. <br /> PAYMENT <br /> I <br /> Appli ant Si ature: <br /> Date: RECEIVED <br /> �� 1 <br /> Title: ��� OCT 2 4 2011 <br /> DO NOT WRITE BELOW THIS LINE SAN JOAQUIN COUNTY <br /> Et4VIRONMENTAL <br /> Date: D/ TH DEPARTMENT <br /> R.E.H.S. Application Approval:-Q- ,) I° Q� �, / <br /> Expiration Date: /�� / Date Paid: fl l l 1 I Cash o heck#• A0�ZL3 Received By: L�' <br /> EHD 45-01 <br />