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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, P Floor, Stockton,CA 95202-2708 f' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd Sqn, 262006 V�'`1Cvlrll Cp APPLICATION FOR A LIMITED ANTITY HAULING EXEM ��1` (1Aa,�, ep ��A LNr To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport less than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with$72.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue,P Floor, Stockton, CA 95202 Medical Waste Hauler Information ❑New ® Renewal Medical Office/Business Name: Gentiva Health Services Medical Office/Business Address: 1588 East March Lane, Suite B3 Stockton CA 95210 City State Zip Code Contact Person: Kristi Halva Phone Number: (209)474-7881 Storage Facility Name: Gentiva Health Services (Collection Point) Storage Facility Address: same as above City State Zip Code .Permitted Treatment Facility Name: Stericycle Permitted Treatment Facility Address: 11875 White Rock Road Rancho Cordova, CA 95670 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: See attached Title: 2. Name: Title: 3. Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste rec s sppq be kept on file at generator's or health care professional's facility. Applicant Signature: Date: 1�t l 1'6 Title: Ruth C. Schwartz, Assistant Secretar DO NO WRITE BELOW THIS LINE R.E.H.S. Application Approval: 1 Date: Expiration Date: ate Pa1d: C Check#• q�3 � L\93 Received By: , EHD 45-01 07/31/06