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May. 23. 2012 10: 33AM No. 0494 P. 2 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT air, 600 East Main Street, Stockton, CA 95202-3029 (209)466-3420 Fax: (209)464-0136 Web: www,sjgov.orglehd 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,transports less than 20 pounds of medics[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 Ora 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: San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202.3029 Medleal Waste Hauler Information ❑ New E Renewal Medical Office/BusinessNamo: T:ALTYGYIf.P. 1FA?n11) CA"rar & elinin Medical QfficelBtlsinessAddress 721 C:a1avPraa SrTOrij _ .— City State _,ZTp code Contact Person: Kathleen Marshall -- Phone Number. (209) 373-2826 Storage Facility Name: �oodb c1cra Medical Group Storage Facility Address: 2401 W_ `i't,rner Ed- 4450 Lodi, CA 95742_ City state Zip Code Permitted Treatment Facility Name: _ Stericycle Permitted Treatment Facility Address: 11575_White_Rock Rd. Rancho Cordova, CA _ 95742 City state Zip Code List all employee names and titles authorized to transport the medical waste([f more than 3, attach info): 1. Name: Maria Barron Title: Lead Receptionist 2. Name: Diane Baba co Title: CUnic Manager 3. Name: Livvy Jackson Title: Registered Nurse A copy of this exemptlon atar. ng document shall he In employee's possession at all times while transporting mediicai waste. in addition,an copies of medical waste records shn le at a ratod or health care professional's facility. Applicant Signature: Date: Title: Direc ualit Improvement r �y /��7_ � c [ l DO NOT WRITE BELOW THIS LINE d REHS Application Approval: Date: Expiration Date: I 1 Date Paid:�1 1 Cash or Check* Received By: EHp 4"1 11!29111 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION