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P. 2 <br /> 4Joaquin County Public Health ServiZ!- <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATiON FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste management act,, the following <br /> conditions must be met: <br /> T he generator or health care professional generates less than ZO pounds of rnectica(�•� per <br /> than 20 Pounds of medical waste at any one time, maintains a tracking document purauat to week.pteR6 andthegenerator or parent organization has on file one of the fallowing: <br /> �- Medical Waste Management Plan if the generator or parent crganizadon is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE 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 /> 0 New X Renewal Medical Waste Hauler Information <br /> Medical Office/Business Name: Gentiva Health Services (formerly Olsten Health services) <br /> Medical Office/Susiness Address: East March Lane, Suite B-3 <br /> City-_ Stockton State: CA <br /> Contact Parson: Patricia Gild Ma Ccde: 95211Q� <br /> Phone '-��?i-474 7 81 <br /> Storage Facility Name: Gentiva Health Services Collection Point <br /> Storage Facility Address: Same as above <br /> City: <br /> State:---.Zlp Code: <br /> Permitted Treatment Facility Name: BFI (Brownie -Ferris Industries <br /> Permitted Treatment Facility Address: 11875 White Rock Road <br /> City: Rancho Cordova <br /> State: <br /> c_�p _Zip Code: 9 742 <br /> List all employee names and titles authorized to transport the medical waste if not enough space, attach information <br /> I- Name: See Attached <br /> 2- Name: Title: <br /> 3- Name: Title: <br /> Title: <br /> A copy of this exemption and a tracking document shall be in employee,!;possession at alt times while Qansporting medkaJ waste. in <br /> additien. all copies of medico w=ta records shall be kept on file alogeneratoes or health caro professional's facility. <br /> Applicant Signature. <br /> Title_ Sandra K. B k <br /> Date: 2 14 / o 0 <br /> 00 Not Write Below This Une Services <br /> R.E.H_S_ Application Approval: <br /> cH4502 1003-96 Date PaidDate. Expiration Date: S // <br /> ;2j ZZt Cash or Check 2 o O/± (circle) Accr Ll3 <br />