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- _ <br /> of <br /> liinr <br /> ..:.. _... ...:. .:..:....•....t. r. ._.............. ............_-.- ...--.....: .. ..... ... - _ <br /> SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 l <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd 1 <br /> APPLICATION FORA LIMITED QUANTITY HAULING EXEMPTION " <br /> °.x <br /> To qualify for a'Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act",the following <br /> conditlons must be met, <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transports less ' <br /> than 20pounds 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 ora <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 blow and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Department AppRO'V <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 <br /> Medleal Waste Hauler Information <br /> 0 New ® Renewal <br /> Medical Office/Business Name: Walgreens#2961 i <br /> Medical Office/Business Address 75 North Ham Lane <br /> Lodi CA 95242 <br /> City State Zip Code <br /> Contact Person: Lyazzat Segizbayeva,on behalf of Walgreen Co. ' <br /> Phone Number. (760)602-8637 1 <br /> Walgreens#2961 <br /> Storage Facility Name: 75 North Ham Lane <br /> Storage Facility Address: Lodi CA 95242 <br /> City State Zip Code <br /> Permitted Treatment Facility Name; Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: Ir y treet, uite 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: Anthony Tran Title: Pharmacist <br /> 2, Name. avid Loth Title: Pharmacist <br /> 3. Name: Dennis McComb Title: Pharmacist <br /> A copy of this exemption and a tracking document shalt be in employee`s possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shalt ke t on file at generator's or health care professional's facility. <br /> Applicant Signature: ' Lyazzat Segizbayeva,On behalf of Walgreen Co. Date: <br /> 11/26/2012 j <br /> Title: Regulatory Complian Coordinator, 3E Company <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: ( Date: 4Z11 I (ZL <br /> i <br /> Expiration Date:. 1 Date Paid: /,�/I Cash or��: ?� .deceived By: <br /> EHD 45-01 6012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />