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Rp <br /> 4 <br /> " ...... :' ...... ................... :. ................ ................. .......... .. ..... .. .. ....... Iva <br /> f <br /> fnJ t <br /> SAN JOAQUIN COUNTY U <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> !"S <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 - <br /> a 209 468-3420 Fax: 209 464-0138 Web:wwws ov.or /ehd <br /> aR� ( } ( } 19 9 w <br /> APPLICATION FORA 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, transports less <br /> than 20 pounds of medical waste at anyone 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 j <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 A,PPRO' <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information . <br /> 0 New Pir Renewal <br /> Medical OfficelBusiness Name: Walgreens#4343 <br /> Medical Office/Business Address 29 E March Lane <br /> Stockton CA 95207 <br /> City state Zip Code <br /> Contact Person: Lyazzat Segizbayeva, on behalf of Walgreen Co. <br /> Phone Number: (760)602-8637 <br /> Walgreens#4343 <br /> Storage Facility Name: 29 E March Lane <br /> Storage Facility Address: Stockton CA 95207 <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: Bunnaunuch Title: Pharmacist <br /> 2, Name: HuongTran Title: Pharmacist <br /> 3. Name: Maria-Jocelyn Title: Pharmacist <br /> A copy of this exemption and attacking documents hall be in employee's possession at all times while transporting medical waste. in addition,all copies of <br /> medical waste records shall K t on file aE generaEor s yr healthcare professional's facility. <br /> Applicant Signature: Lyazzat Segizbayeva,On behalf of Walgreen Co. Date: 11/26/2012 <br /> Title: Regulatory Complian Coordinator, 3E Comoanv <br /> 00 NOT WRITE BELOW THIS LINE <br /> RENS Application Approval: —� '� Y�-�' �--- Date: 2 J_A l_A1— <br /> Expiration Date:I'Ll51_L[3_Date Paid:/;�,lf0 l I;-Cash 4r' hec ":3G2.2.3�Received By: <br /> EHD 45-01512112 APPLICATION FOR A LIMITED QUANT TY HAULING EXEMPTION <br />