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q�`cN SAN JOAQUIN COUNTY <br /> LCff Y <br /> Q' za E10IP._. <br /> :ONMENTAL HEALTH DEPART 1T � It,� <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Weh:www.sjgov.org/ehd <br /> SAPd,DA(-iffN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIFiGNMENTAL <br /> HEALTH DEPARTMENT <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$72.00 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 ® Renewal <br /> Medical Office/Business Name: Gentiva Health Services <br /> Medical Office/Business Address: 1588 East March Lane, Suite B3 <br /> Stockton, CA 95210 <br /> City State Zip Code <br /> Contact Person: David Rutter <br /> Phone Number: (209)474-7881 <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: Stericycle <br /> Permitted Treatment Facility Address: 11875 white Rock Road <br /> Rancho Cordova, CA 95670 <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 the attached list Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and at document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medic waste rec ds s II be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: �Z 7 `1)7 <br /> Title: Ruth C. Schwartz, Assistant Secrfty <br /> DO NO WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: �' Date: L may <br /> Expiration Date: J-7 I /Date Paid: 6? Check q9,Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />