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G� SAN JOAQUIN COUNTY � pAYME'NI <br /> ENNMENTAL HEALTH DEPARTME`14T �EIVED <br /> .. 304 East Weber Avenue, P Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd DEC 2004 <br /> c,�aRN <br /> JOAQUIN <br /> APPLICATION FOR A LIMITE TITY HAULING EXEMPT1"NVIRONM COUNTY <br /> NVIRONMENTAL <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-Departnnetrt _-- <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3r'Floor, Stockton,CA 95202 t <br /> Medical Waste Hauler Information <br /> ❑New [2 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;Aj <br /> e kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 11/29/04 <br /> Title: t Secre r <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: /� ec/ Cash or : Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />