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- �, cel oPo`1N'c • SAN JOAQUIN COUNTY Q , ENVIRONMENTAL HEALTH DEPARTMENT DEC 19 2011 600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd PERMIT/SERVICES 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 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: FILE C!J'P " San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information New Renewal Medical Office/Business Name: Gentiva Health Services Medical Office/Business Address 10100 Trinity Parkway, Suite 450 Stockton CA 95219 City State Zip Code Contact Person: Kristi Halva Phone Number: 209-474-7881 Storage Facility Name: Gentiva Health Services Storage Facility Address: Same as above City State Zip Code Permitted Treatment Facility Name: Stericycle Permitted Treatment Facility Address: — 11875 White Rock Road Rancho Cordova, CA 95670 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: See attached list 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 be kept on a e erator's or health c re fessional's facility. Applicant Signature: Date: u Title: Ruth C. Schwartz Assistant Secreta DO NOT WRITE BELOW THIS LINE REHS Application Approval: �S1e;� �rr oxK} _fn , �1 Date: /,��/za� Expiration Date:�/ �� / ` Date Paid:�/ �_l / 11 Cash or Check#:1 "t4 Received By: EHD 45-0111129111 APPLICATION FOR A IMI�TED QUANTITY HAULING EXEMPTION