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wn. <br /> aulry £i <br /> SAN JOAQUIN COUNTY JAN — 9 2012 <br /> ENVAONMENTAL HEALTH DEPARTMENT <br /> ._ ; ., :. . 600 @est Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH <br /> (209)468-3420 Fax: (209)464-0138 Web: www,sigov.org/ehd PERMIT/SERVICES <br /> �1FOR <br /> APPLICATION FOR LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fora"Limited Quantity Hauling Exen4tion" 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 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: ), <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New 9 Renewal <br /> Medical Office/Business Name: Walgreens#2770 <br /> Medical Office/Business Address 7929 ower Sacramento Road <br /> Stockton CA 95210 <br /> city state Zip Code <br /> Contact Person: Lyazzat Segizbayeva Agent for Walgreens Corporation <br /> Phone Number: (760)602-8700 <br /> Walgreens#2770 <br /> Storage Facility Name: 7929 Lower 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: 9350 irb)r Street, Suite 300 <br /> Houston TX 77054 <br /> City State Trp Code <br /> _ List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1. Name: Carl Hammel Title: Pharrl acist <br /> 2.Name: David Kang _ Title: Pharmacist <br /> 3, Name: Sandra Kanemoto 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 op,file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12/06/2011 <br /> Title: Agent for Walgreens C rporation <br /> DO NOT WRITE BELOW THIS LINE <br /> RENS Application Approval:—� _ j _ A �.� - p Date: ink <br /> (/09 /(Z— <br /> Expiration <br /> /(Z <br /> Expiration Date: �L 1 3t I (L Date Paid: I !�l Ili Cash or Check#:Z�y0 3 3Receive By: T p�l <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUAN71TY HAULING EXEMPTION <br />