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_ U I <br /> SAmJOAQU|N COUNTY <br /> ����U���Q0E���� U����7HK������88��� � <br /> ~~ HEALTH ~~ } <br /> 18GOEast Hazelton Avenue, Stockton, CA852U5-G232 � <br /> (2DS)4G8-342OFax: (2OQ)4G4-0138Web:vvmxw 'gmv.oro/and <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify | <br /> ^ ! <br /> conditions must bamet: <br /> ' <br /> The generator or health care professional generates less than 20 pounds of medical waste per vn*ok transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the <br /> generator orparent organization has unfile one ofthe following: <br /> 1 Medical | <br /> ' ' | <br /> small quantity generator required toregister pursuant toChapter 4. <br /> 2. Information Document|f the generator o | required to <br /> regi�arpursuant bo(�hephar4. - <br /> / <br /> Please complete the information below and mail with $77.00fee to: <br /> San Joaquin County Environmental Health Department AP»` °~-- ILD / DEC � � �N�� ! <br /> Medical Waste Management Pmg�m ` ��� � - ~~~~ ' <br /> 18G8East Hazelton Avenua Stockton, �AQ5�O5-823� -- / / sw^�oxno�cOu�r <br /> ' ' sxV1nowuENTAL <br /> HEALTH DEPARTMENT . <br /> Medical Waste Hauler Information <br /> O New 041 Renewal ` <br /> ' ! <br /> Medical Office/Business Name: Walgreens#0716 ' <br /> Medical Office/Business Address /u2North Jack Tone Road,#n <br /> Ripon CA 95366 <br /> City suau, Zip Code <br /> Contact Person: Gulsinay Harris, On behalf of Walareen, Co. <br /> Phone Number: (760)602-8700 <br /> ' <br /> Walgreens#9716 <br /> Storage Facility Name: 1oaNorth Jack Tone Road,#R <br /> Storage Facility Address: Ripon <br /> Permittedcity State Zip Code <br /> Treatment Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: 9350 Kirby <br /> Houston TX 77054 <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: Andrea J. Bartels Title: Pharmacist <br /> 2. Name: /\ Title: Pharmacist <br /> 3. Name: Title: <br /> - <br /> A copy of this exemption and a trackIng document shall be In employee's possession at all times <br /> while transporting medical waste. maddition,all copies o, <br /> medical waste records shall be pt on file at- `professional's facility. <br /> Applicant `_;�~�^�'* Date: 12/05/2013 <br /> /ue: Re.qulatory Compliance Coordinator, 3E Company <br /> Q0 NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: jj,1.ZL/-a <br /> Expiration Date: uatnrum: Cwux Received By: <br /> sxow5-0norJ1z APPLICATION FOR»LIMITED QUANTITY HAULING EXEMPTION <br />