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r <br /> YQUt`� IV <br /> SAN JOA UIN COUNTY i—� EIVj((( <br /> .<� E IRONMENTAL EALTH DEPAR YY •^. <br /> 600 East Main Street, Stockton,CA 95202-3029 100$ <br /> c. / Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.org/ehd SAiV J®AQUf <br /> E/VVIROty 4 C®UN7y <br /> APPLICATION FOR A LIMITE ANTITY HAULING EXEMP 06PA, L <br /> rr <br /> A <br /> Rruew <br /> To qualify for a"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,transport less <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the following: <br /> 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br /> or a small 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 <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑New X Renewal <br /> Medical Office/Business Name: Gentiva Health Services <br /> Medical Office/Business Address: 1776 West March Lane, Suite 150 <br /> Stockton CA 95207 <br /> City State Zip Code <br /> Contact Person: Kristi Halva <br /> Phone Number: (209)474-7881 <br /> Storage Facility Name: Gentiva Health Services <br /> Storage Facility Address: Same as above <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle <br /> Permitted Treatment Facility Address: 4134 west Swift Avenue-Per Kristi Halva <br /> Fresno CA 93722 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1.Name: See attached list Title: <br /> 2.Name: Title: <br /> 3.Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession all times while transporting medical waste. In <br /> addition,all copies of medical waste records s all be pt on file at generator's o ealth care professional's facility. <br /> Applicant Signature: Date: 0 <br /> Title: Ruth C. Schwartz,Assistant Secretary <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: -- _ Date: <br /> Expiration Date:�_/ J / Date Paid: Cash o heck# yy Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />