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' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> -6232 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Acf,the following <br /> conditions must be met <br /> The generator orhealth care professional generates less than 20 pounds of medical waste per week,transports less <br /> than 2Opounds ofmedical waste adany one time, maintains a tracking document pursuant b»Chapter 8and the <br /> generator nrparent organization has onfile one ofthe 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 toregister pursuant toChapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required to � <br /> register pursuant boChapter 4. <br /> ' <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department �����w~~ � <br /> yNadioa|VVaotoK8anagomontPnognynn �="^ ~ ~--- <br /> 18G8East Hazelton Avenue, Stockton, OAQS2O5~8232EWOtONMENTAL <br /> xEALTd"=-R'~--' <br /> ONew XRenewal <br /> ' <br /> 8Xedh:nl Name: Walgreens <br /> Medical Offioe/BueinesoAddneoa 7929Loweoumux"*nmnvuu <br /> Stockton CA 95210 <br /> Cit' <br /> State Zip Code <br /> Contact Person: Gulsinay Harris, On behalf of Walgreen, Co. <br /> Phone Number: <br /> ' VV�g�one#277O <br /> Storage Fmc0�yName: <br /> 7S29Lower Sacramento Road <br /> Storage Facility Address: Stockton CA 95210 <br /> city State Zip Code <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: <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: Jonathan L. Szkotak /ma: Pharmacist <br /> 2. Name: Adam M. Kaye Title: Pharmacist <br /> 3, Name: Title: Pharmacist <br /> A copy of this exemption and a tracking document shall be In employeWs possession at all times while transporting medical waste. maddition,all copies of <br /> medical waste records shall be kept onfile atgenerator's mhealth care facility. <br /> Applicant Date: 12/05/2013 <br /> Title: Requlatorv'Compliance Coordinator, 3E Comr)any <br /> DC) NOT WRITE BELOW THUS LINE <br /> REHSApplication Approval: <br /> ExpiradunDate: Date Paid: Cash Received"»_ <br /> s*o*o-01mo1x APPLICATION FOR ALIMITED QUANTITY HAULING EXEMPTION <br />