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2-10-2000 10: 16AH FRO( . P. 2 <br /> t San Joaquin County Public Health Services <br /> Environmental Health Oivision <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 Act", the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Ctiapter 6, and the <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 /> 2- Information Document if the generator or parent arganization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAID 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 /> Medical Waste Hauler Information <br /> 0 New r Renewal <br /> Medical Off1Ge/13usiness Name:, Gentiva Health Services (formerly Olsten Health Services) <br /> Medical OfficefBusiness Address: 1b88 East March Lane, Suite B-3 <br /> City- Stockton State: CA asp Code: 95210 <br /> Contact Person: Patricia Gild Phone* - -7 81 <br /> Storage Facility Name: Gentiva Health Services (Collection Point) <br /> Storage Facility Address: Same as above <br /> City: State: _ _ - --_Zip Code.• <br /> Permitted Treatment Facility Name: BFI (Browninq-Ferris Industries) <br /> Permitted Treatment Facility Address: 11875 White Rock Road <br /> City: Rancho Cordova State: cA Zip Code: ._9742 <br /> ,r I��II�II��LwIIA� ���A��A• I�M <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: See Attached Title: <br /> 2- Name: Title: <br /> 3- Name: Title: -- <br /> A copy of this exemption and a tracking doGAunent shall bts in empiayee's possession at all times while transporting medical wawa. In <br /> additlan. all copies of medics Ste records shall bs ke on fiie a neratoes or health care professional's facility. <br /> Applicant Signature. <br /> Title• Sandra K. Beck, A - Date. 2 / 14 / 00 <br /> Services <br /> Do Not Write Below This Line <br /> R.E.H-S_ Application Approva. Date:.! j /dOF, iration Date= 2/ 3//00 <br /> EH4502 1043-96 P Date Paid 0C Cash or Check T (circle) Acct_ _ <br />