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I oAQvl"' AN .10 QUIN UNTY RECEIVED �.•:®, .o ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DEC 13 2013 eq•-�: a�P (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd ��FOR ONMENTAL HEALTH APPLICATION FOR A LIMITED QUANTITY HAULING EXEMP�RMITISFRVICES 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 less 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 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 $77.00 fee to: PECY"/ED I San Joaquin County Environmental Health Department 1�. ' 'ROV ®EC Medical Waste Management Program :, say CoA ' 3 2013 1868 East Hazelton Avenue, Stockton, CA 95205-6232 H E'7Rp yo�utv7y Medical Waste Hauler Informatlon 0 New a Renewal Medical Office/Business Name: Hospice of San Joaquin Medical Office/Business Address 3888 Pacific Ave Stockton CA 95204 City State Zip Code Contact Person: Kerrie A Biddle Phone Number: (2099) 957-3888 Storage Facility Name: Hospice of San Joaquin Storage Facility Address: 3888 Pacific Ave cityStockon Cktate 95204 zip Code Permitted Treatment Facility Name: Steri cvcl e Permitted Treatment Facility Address: 4135 West Swift Road Fresno CA 93722 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: CFF ATTACHFD 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 b kept on file at ge is or heap care professional's facility. Applicant Signature:; Date: T Title: Chi F n qDO NOT WRITE BELOW THIS LINE REHS Application Approval: Date: Expiration Date: ML/ /1� Date Paid: 19,/ ,3//S Cash oCCheck Received By: fr EHD 45-01 5012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION