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,O pq U t ty C <br /> o SAN JOAQUIN COUNTY F�HYENI. <br /> ENMENTAL HEALTH DE T t►= <br /> 4 VRECEIVED <br /> 304 East Weber Avenue, 3rd Floor, Stockto CA 20 <br /> o P Telephone:(209)468-3420 Fax:(209)468-3433 rg/e1 DEC P 200 <br /> COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI( jOANVIRONMNMENTALTAL <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$70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New [a 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: Patricia Gild <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 attached 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 at all times while transporting medical waste. In <br /> addition,all copies of medical waste rec sl Il be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 11/29/04 <br /> Title: Ruth C. Schwaltz. Assistant Secre r <br /> DO NOT WRITE B LOW THIS LINE <br /> R.E.H.S. Application Approval: Date: —IZ/�'7(} <br /> Expiration Date: 05—Date Paid: / /Cash or ee #: —,� �Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />