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FEB-01-2007 THU 03: 12 PM FAX N0. P. 02 <br /> 01/31/2907 15:10 20 433 EHA PAGE 92 <br /> SANJOAQUNCO.UNTY <br /> ENvmoNN,IwrAL Lm JDEPAR.TmmqT e6 <br /> 304 Last Weber Avenue,3`4 Floor,Stockton,CA 95202-270$ <br /> Tdegphonc(209)466.3420 Fay(209 468-3433 Web:www.skoy.org/ohd ?006 <br /> APPLICATION FOR A LBUTED Q1 7ANTITY.11ALMANG R 02CCU <br /> To qualify for a"Limited quantity Hauling Exenwdoe purst Pzt to the"Medical Wasto Management Aat".the following <br /> conditions must be met; <br /> no generator or health care professional generates W,s than 20 pounds of tnalicaal waste per week,liauspoart less <br /> dw 20 pouads of medical waste at any one time,Mai 440 a ftc4dng doeamont pursuant to Chapter b and the <br /> generator or parent organization has on file oue of thefollowing: <br /> 1. Adedi�cal i�asle ltQ'mra�m�ti'Flan if the for or P organization ie a large quantity tcrc <br /> or a small quantity generator required to re gista pmunt to Chapter 4. <br /> 2, ln,fvrmafCon,Document if the goner ator or I art=organization is a small quantity generator not required <br /> to register pursuant to CLgter 4. <br /> Please complete the Informadon below and mall with$72.0 0 he to: <br /> San Joaquin County'F Vironmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,314 Floor,Stockbon,CA 95202 <br /> e iCaI aste Ha aler Information <br /> 0 New IM Renewal. <br /> mettitcal OtflceBUsiness Name: Gent:i.va ff"Iti Services <br /> Medical Offtce/Susitiess A Lane Suite 83 <br /> Stockton CA 95210 <br /> City State zip Cede <br /> Contact Pmon: Krish Balva <br /> Phone Nim ber: (2091474--7M— <br /> Storage <br /> 2 9 7Storage Facility No= Gj&nt:iva Roalth Serviees (Co7llactlon Point) <br /> Storage Facility Address: same as Abve <br /> city state Zip Codd <br /> -Pmvittod Treatment Vardk dame: Steri aycla <br /> Petted TreatmentFacllityAddmss: 11$75 White Rock 95ad <br /> Rancho Cordon CA — 95670 <br /> 93670 <br /> City State ZIP Code <br /> List all employie names and titles authorized to ftwuport the edieal waste(If more then 3,attach infb): <br /> 1.Name: see actaahod Title: <br /> 2.Name; Title- <br /> 3.Nam: This: <br /> A CAVY of this cxemyfion and a trwjft doeanlent Abad be In woloyeei I PAEeealaa At A tlmea white tr110Wrttne media I waste In. <br /> addidon,all soples et medlcat waste a be oa ale at ed1w xterls or bealtb cart,prat!ante®facility. <br /> Applicant S,iga'ture: pate, 11t.�y�1 t <br /> Titt®: . 3ath Assistant Secretirg�7 <br /> DO N. 'WXtITL BELOW THIS LINE <br /> R.&H,S,Applica Appmv:al: Date: .al, l-0-60 <br /> B"iration Dxtti: 12 13/ /mate d: / i dk I goorK Cho*0• 1 F"elved BY: <br /> EM 4S-u9 <br /> a1ISLb6 ' <br />