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VI s°•� _ SAN JOAQUIN COUNTY I/_VI2-11a -'? ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton,-CA 95205-6232 '. (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd s �IF'OX _. APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION S. To qualify for a'Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act",the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transports less ' than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. 'Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. i I Please complete the information below and mail with $77.00 fee to: A 7� i San Joaquin County Environmental Health Department t•ir PROV Medical Waste Management Program r 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Medical Waste Haulier Information 0 New 9 Renewal Medical Office/Business Name: Walgreens#9716 Medical Office/Business Address 102 N Jack Tone Road#R Ripon CA 95366 City State Zip Code Contact Person: Lyazzat Segizbayeva, on behalf of Walgreen Co. Phone Number. (760)602-8637 I Walgreens#9716 Storage Facility Name: 102 N Jack Tone Road#R Storage Facility Address: Ripon CA 95366 City state Zip Coda Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment f=acility Address: 9350 Kirby Street, Suite- 300 Houston TX 77054 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3,attach Info): 1. Name: Andrea Bartels Title: Pharmacist 2. Name: Anne ng ahl Title: Pharmacist 3. Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records shall- a a on filo at generator's or health care professional's facility. Applicant Signature: Lyazzat Segizbayeva,On behalf of Walgreen Co: Date-, 11/26/2012 Title: Regulatory Complicue Coordinator, 3E Comoanv _ D0 NOT WRITE BELOW THIS LINE REHS Application Approval: Date: _XTA1 IJ Expiration Date:jjjA_j I I Date Paid: /-2--/ � l r Cash o Che :��10 Received By: EHD 4501 5012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION