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0 <br /> o San Joaquin County Public Health <br /> q Sees <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fora"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management A&,', the following <br /> conditions must be met: <br /> l waste per week, <br /> ess <br /> T generator or health care professional one times less <br /> tains a trcl<ing doccpounds of me�nt P ant to Chaptter 6,oand rts l the <br /> than 20 pounds of medical wase at Y <br /> generator or parent organization has on file one of the fallowing: <br /> 1_ Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> .^,t if the generator or parert organization is a small quantity generator not required b <br /> 2- lr. oTration Dccume <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL Wit T i $ali cE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New C& Renewal <br /> Medical Office/Business Name:. <br /> Gentiva Health Services <br /> Medical Ofn"ce/Business Address: 1588 East March Lane, SuS�eB-3 <br /> eCA Zp Code: 95210 <br /> City: Stockton Phone :209/474-7881 <br /> Contact Person: Patricia Gild <br /> Gentiva Health Services (Collection Point) <br /> Storage Facility Name: <br /> Same as above Zp Code: <br /> Storage Facility Address: State: <br /> City: <br /> BFI (Browning-Ferris Industries) <br /> Permitted Treatment Facility Name: 11875 ite Rock Road <br /> Permitted Treatment Facility Address: State: C L'p Code: 95742 <br /> City: Rancho Cordova <br /> List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. <br /> See attached Title' <br /> Name: Title: <br /> 2_ Name: Title: <br /> 3_ Name: <br /> document shall be in employee's possession at all times while transporting medical waste- in <br /> A copy of this exemption and a tracking essionars facirity. <br /> addition. all copies of medical y�raste records shoo be kept an file at generators or health tate prof <br /> Applicant Signature: X Cij <br /> Title. <br /> Sandra K. Beck, Direc State olicy & Regulatory Support Date: 12 /27 /O1 <br /> Do Not Write Below This Line <br /> Date / / Zapiration Date:-3 <br /> / OZ <br /> 2.E.H.S. Application Approval: j <br /> EH4502 10-03-96 <br /> Date Paid / / O Cash or Check # 3t lPl 01 J (circle) Acct <br />