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AYMENT <br /> OO117640 <br /> �ANCj P RDECEIVE JOAQUIN COUNT1 1 L <br /> ENVIRONMENTAL HEALTH DEPARTMENT FEB - 7 2011 <br /> 600 East Main Street,Stockton,CA 95202-3029 SAN JOA <br /> QUIN;;.� „ _P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ENVIROMEN COUNTY <br /> � HEALTH DEPARTMENT <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quaa�lkF'ju i$j mption"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. F l� 00 k 1l 9(0\ <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Department P r\C).5 3 b0 LAE) <br /> Medical Waste Management Program 2� 1 <br /> 600 East Main Street, Stockton,CA 95202-3029 C1 b 63 <br /> Medical Waste Hauler Information <br /> ®New ❑Renewal <br /> Medical Office/Business Name: Walgreens#9716 <br /> Medical Office/Business Address: 102 N Jack Tone Road#R <br /> Ripon CA 95366 <br /> City State Zip Code <br /> Contact Person: Karina Aguilar,Agent for Walgreens Corporation <br /> Phone Number: (760)602-8887 <br /> Storage Facility Name: Walgreens#9716 <br /> Storage Facility Address: 102 N Jack Tone Road#R <br /> RiDon 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 /> 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: Anne Engdahl Title: Manager/Pharmacist <br /> 2.Name: Andrea Bartels Title: Pharmacist <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 records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: I,- nss--"—'"' Date: 12(02/2010 <br /> Title: Agent for Walgreens Corporation <br /> DO NOT WRI E BELOW THIS LINE <br /> R.E.H.S.Application Approval: n _ Date:15 1 1116 k <br /> Expiration Date: / / Date Paid: oA,/ 1 / C-mh-erCheck#: Received By: \ Y Z- <br /> EHD 45-01 <br /> 11/19/08 4"7 <br />