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12/31/2002 09:13 209468304 FIFTH FLOOR PAGE 02 <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANT17Y HAULING EXEMPTION <br /> To qualify for a "Limited (Zuantity 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, tramparts 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 organizabon has an file one of the following: <br /> Medical Waste Adanagement Plan it the generator Or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4- <br /> jnrom,,aJon Dor—ament if the generator or parent Organit2ticn ts a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 F—r.!E TC: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 01 New 0 Renewal <br /> Medical Office/Business Name-,• Gentiva Health Services <br /> Medical officeteusiness Addre ;:�1588 East March Lane Suite A3 <br /> Stockton State: - CA Zip Code: 95210— <br /> City: Patricia Gild phone tr" 2021474—ZB81. <br /> Contact Parson: <br /> G,entivam'7ealth Services (Collection Point) <br /> Storage Facility Name; Same as above <br /> Storage Facility Address: Stzte:�Zlp Code: <br /> Permitted Treatment Facility Name: Stericycle <br /> 8 7 5 T-r- Rock lf R nn ci <br /> Permitted Treatment Facility Address: State: CA Zip Ccde.--25j2LL— <br /> city, Rancho Cordova <br /> List all employee names and titles authafted to Umnsport the medical waste. if not enough space, attach information. <br /> Name' See attached Tittle: <br /> Tide: <br /> 2- Name:- Tide: <br /> 3- Name: an at OU tineas while tr�parwq medcw waste. In <br /> an and a mai"g dcc=e shag <br /> Kept an Me heam cam proWsionars facStY. <br /> A copy of this txemPd' tnt 132111 be ifl Offl <br /> ;addltlarl, an copiess at me`gacal mcords$Sisal!Sisal!eat =' <br /> Applicant Signature: <br /> Jean A. Buc a, Lead ecialist <br /> Tilde: <br /> Corporate Licensing & Regulatory Dept. <br /> Do Not Write Below This Line <br /> Date:/ Q1 iratlon Gate-. <br /> R-E-H.S.Application Approval- <br /> Paid j Ca5h QCe <br /> Date10 h (circle) A:4�� <br /> EH4502 1043-96 <br />