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aQul!YE' SAN JOAQUIN COUNTY <br /> ENVIRQiNMENTAL HEALTH DEPARTMENT <br /> JAN s 9 2012 <br /> ?� 600 Eat Main Street, Stockton, CA 95202-3029 <br /> (209)468-3420;Fax: (209)464-0138 Web:www.sjgov.orglehd ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION/ <br /> i;)i <br /> To qualify for a"Limited Quantity,Hauling Exemp(.pn"pursuant to the"Medical Waste Management Aot the following <br /> conditions must be met: tl' <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: a<= <br /> F ILE <br /> San Joaquin County Environmental Health Department ± <br /> Medical Waste Management <br /> laa+J2 <br /> Program/Cw� <br /> r nn Fast Main Street Stockton,-C <br /> -- 0 -1029 <br /> MedICaI Waste Hauler Information <br /> ❑ New IJ Renewal <br /> Medical Office/Business Name: Walgreens#4343 <br /> Medical Office/Business Address 77—EMarch Lane <br /> Stockton CA 95207 <br /> City State Zip Code <br /> Contact Person: Lyazzat Segizbayeva,Agent for Walgreens Corporation <br /> Phone Number: 860 602-8700 <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: Debra Short Title: Manaoer/Pharmacist <br /> 2. Name: Maria-Jocely Gayagoy Title: Pharmacist <br /> 3. Name: An Nguyen Title: Pharmacist <br /> 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 <br /> medical waste records shall be kept on file77- <br /> ratoes or health care professional's facility. <br /> Applicant Signature: Date: 12/06/2011 <br /> Title: Agent for Walgreens Corooratlon <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval„ Date: t AIA-9_ <br /> Z,Qg0o3303Z5Z. <br /> Expiration Date: )?'1�� / (2-Date Paid: I /�1 1?Cash or Check#: Received By: <br /> EHD 4501 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />