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SAN JOAQUIN COUNTY N ENVWNMENTAL HEALTH DEPARTMOT 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 �. `P• (209)468-3420•Fax:(209)468-3433 • Web:www.co.san-joaquinca.us/ehd 9�►FOR� APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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,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$70.00 fee to: San Joaquin County Environmental Health Department , cou A,�j Medical Waste Management Program-.. 304 East Weber Avenue, P Floor, Stockton, CA 95202 Medical Waste Hauler Information ❑ New ®Renewal Medical OfficeBusinessName: Rchahyocus Home Health, Tnc. ' MedicalOfficeBusinessAddress: 1 31 3 TAI. Rohinhood nr. , suite A-4 Stockton, CA 95207 City State Zip Code Contact Person: navid Raposa Phone Number: 209-472-7005 Storage Facility Name: SAA Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: Medaden 1:1iomerlical Inc - Permitted Treatment Facility Address: 22711 S western Ave ^'orrance rA 90501 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1. Name: Cheri Newcomh, RNT Title: npCS 2.Name: Torrey Stadtner, RN Title: Nursing Supervisor 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: 4 Date: 12/01 /03 Title: Administrator DO N T WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: /3(_/ Date Paid: IZ'/ / 0 3 Cash Check • 108' Received By: EHD 45-02-001 i nivnnm rwrnw..wrnrwFNr1l n,m—Nngnnnninwrn�nwenRrm,,,,mmnvrn+nrnn+*rnrwi,•nnnn.+nn.. ,rri+nn�m�nnnrnn�ninnnnen+rn.++nwrnnr�• ,,, .,•. .