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Sa loaquin County Public Health Servo Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Aet% the following conditions must be met The generator or health care professional generates less than 20 pounds of medical waste per week, transports less 'han 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 S67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information C1 New%R Renewal Medical Office/Business Name: Gentiva Health Services Medical office/Business Address: 1588 East March Lane State BCA _ Tip Code: 95210 City: Stockton Phone #r, 209/474-7881 Contact Person: Patricia Gild Storage Facility Name: Gentiva Health Services Collection Point) Storage Facility Address: Same as above State: Zip Code: City: Permitted Treatment Facility Name: BFI (Browning Ferris Industries) Permitted Treatment Facility Address: 11875 White Rock Road State: CA Zip Code: 95742 City: Rancho Cordova List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. See attached Title: 1- Name: Title: 2- Name: Title: 3- Name: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in addition, ail copies of medical waste records shall be kept on file at generatoes or health care professional's facility. Applicant Signature: Title: SAndra K. Beck, Director, State Polic & Re ulator Support Date: 12 / 22 /00 Do Not Write Below This Line R.E.H.5. Application Approval: Date: /^ ! Expiration Date: /7 131 I EH4502 10-03-96 Date Paid l Z/ ZR! d Cash or heck 2��90 (circle) Acct