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`` T,, • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> :. 600 East Main Street, Stockton, CA 95202-3029 <br /> ' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/e fd = COPY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑New ❑ Renewal CHANGE OF ADDRESS <br /> Medical Office/Business Name: Gentiva Health Services <br /> Medical Office/Business Address: 10100 Trinity Parkway, Suite 450 <br /> Stockton CA 95219 <br /> City State Zip Code <br /> Contact Person: Kristi Halva <br /> Phone Number: 209-474-7881 <br /> Storage Facility Name: Gentiva Health Services <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 list 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 shall b kept on file at generator's or health care professional's facility. <br /> 7 <br /> Applicant Signature: ); Date: <br /> Title: Ruth C. Schwa z ssistant Secretar <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date:LZ. Date Paid: / / Cash or Check#: Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />