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SAN JOAQUIN COUNTY REC <br /> MENT <br /> EIV <br /> y { ENOONMENTAL HEALTH DEPARTMOOT D ED. <br /> 304 East Weber Avenue, 3'd Floor, Stockton,CA 95202-2708 EC 15 2003 <br /> (209)468-3420•Fax:(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd SAN JOAQUIN <br /> a FoR�� ENWRONMENTANTy. <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMP"I'Iu�oEPARTMENT <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 Cou;i y Lnvironmcntal Health Depa. ent o <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New U 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 records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: a , &J& Date: 12/11/03 <br /> Title: Jean A. B7dAta, Lead Specialist <br /> DO NOT WRITE ELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: j-/-g-/(9 <br /> Expiration Date: Date Paid: Cash or k)#: Aflr3 Received By: KX <br /> EHD 45-02-001 <br /> 1017/2003 <br /> 1i>IIA����I IIIIRI}IP�F wN,°' 91III III ''",Iu'IIIIiiI�P���II�iP1PIAf��PIIII���III�IIiIIRllhgn�ll��hl�''��III�II1111R�h�gly�uri��gi�I�lAIIgIAIAII�IIIAI�IPqIqIIWIIMI11111AlAlIAF u��91AA1111A111N111�ARIihinmmlAl�I�m ��nlA�nmennrr , . , nmA�, n . ,,, <br /> i nnni�we�iwnmmwn�+ <br />