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... ................ - ..... .. .. ¢ <br /> „ L <br /> SAN JOAQUIN COUNTY i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 `f <br /> ` P (209)468-3420 Fax: (209)464-0138 Web:www.sjgovorg/ehd <br /> �t <br /> APPLICATION FO.R A LIMITED QUANTITY HAULING EXEMPTION <br /> lr <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act",the following n, <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 any one t€iTte, 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 /> PIease complete the information below and mail with $77.00 fee to,. <br /> San Joaquin County Environmental Health Department "PROV l� <br /> Medical Waste Management Program ` <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i <br /> Medical Waste Hauler Information <br /> i <br /> 0 New In Renewal <br /> Medical Office/Business Name: Walgreens#2770 <br /> Medical Off€ce/Business Address 929 ower Sacramento Road <br /> Stockton CA 95210 <br /> City State Zip Code <br /> Contact Person: Lyazzat Segizbayeva on behalf.of Walgreen Co. <br /> Phone Number; (760)602-8637 <br /> Walgreens#2770 <br /> Storage Facility Name: 7929 Lower Sacramento Road <br /> Storage Facility Address: Stockton CA 95210 <br /> City State zip Coda <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: lr y treat, uite 300 <br /> Houston TX 77054 <br /> City State Zip Cods <br /> List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): <br /> 1. Name: Adam Kaye Title: Pharmacist <br /> 2. Name: Arnabel Catabay Hernandez Title: Pharmacist <br /> Carl Hammel Title: Pharmacist l <br /> 3. Name: � <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 pt n file at ganarator's or health care professionars facility. <br /> Applicant Signature: Lyazzat Segizbayeva,On behalf of Walgreen Co. pate: 11/26/2012 <br /> Title: Re ulatory Complian Coordinator, 3E C n _ <br /> n DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval-t_ l Q� Date: <br /> Expiration Date: (til LI l_j�)_Date Paid: 1.11 /0I 0- Cash or ec :Z� ;� Received By: <br /> EHO 45-01 512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />