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�i <br /> i re <br /> D p <br /> oAat't 'SAN JO QUIN COUNTY <br /> ENVIRC�I`IVMENTAL HEALTH DEPARTMENT <br /> Q.=• - -.., JAN - 9 2012 <br /> 600 El Main Street, Stockton,CA 95202-3029 <br /> • ."0." " 'i. <br /> (209)468-3420=fax: (209)464-0138 Web:www.sjgov.orgfehd ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> ci�r7ri� <br /> APPLICATION FOR LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a'"Lirnited Quantity Hauling:Exemptn" pursuant to the"Medical Waste Management Act",the following <br /> conditions must be rret: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,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 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 or a <br /> 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 to <br /> 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 /> D New M Renewal <br /> Walgreens#9716 <br /> Medical OfficefBtisiness Name: Wal 9 <br /> Medical Office/Business Address 102 N hack Tone Road#R <br /> Ripon CA 95366 <br /> city State Zip Cade <br /> Contact Person: Lyazzat Segizbayeva Agent for Walgreens Corporation <br /> Phone Number: (760)602-8700 <br /> Walgreens#9716 <br /> Storage Facility Name; 102 N Jack Tone Road#R <br /> Storage Facility Address: Ripon CA 95366 <br /> City State zip Code <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment.Facility Address: 9350 Kirby Street, Suite 300 <br /> w 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 /> v. 'I.Name: Anne Enadahl Title: Manaaer/Pharmacist <br /> 2. Name: Andrea Bartels Title: Pharmacist <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shaft be In employee's possession at ail times white transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on file at gene tot's or health care professional's facility. <br /> Applicant Signature: Date: 12/06/2011 <br /> Title: Agent for Walgreens Corporation T <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: C� ° — Date: <br /> 71(0000 3303Z�Z <br /> Expiration Date: I Z / �✓�/ �Z Date/'aid: 1 f f IZ Cash or Check#: Received By: 'f'W <br /> EHb 45-0111129A I APPLICATION FOR A IMiTEO QUANTITY HAULING EXEMPTION <br />