Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> � <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify form"UnitedCluantit/HauUngExonmotion^purouanttotha"K0odicoWooteK8anagement Act",the following` <br /> conditions must bamet: <br /> The generator or health rare professional generates less than 20 pounds of medicalwaste 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 orparent organization has oofile 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 ioregister pursuant toChapter 4. <br /> 2. Information Document ifthe generator ogenerator not requiredto <br /> register pursuant toChapter 4. ° PAYMENT ' . <br /> RECEIVED-- <br /> � �) - . | <br /> Please complete the imfomna�on below and mmaOvn� fee to: L/-_UN ! <br /> — � � Aims � <br /> ' K»EC � � Ago \ . <br /> San Joaquin CountyEnvronment |HealthDopartment ^~�� ~ ---- �� / . <br /> K8ed�a|VVoeteK�anagannerdProgram V swwnnwmswTAL <br /> ' <br /> 18G8East Hazelton Avenue, Stockton, CA852O5-G232 *cmzHosnwnxmmNr <br /> Medical Waste Hauler Informatlon <br /> | <br /> O New XRenowai <br /> . . <br /> MedicalOffice/Business <br /> ' 0aox»: Walgreens#2961 - <br /> Medical OffinaDBusinoaoAddress /oNorth Ham Lane <br /> -odi CA 95242 <br /> - <br /> - <br /> Contact Person: ' <br /> Phone Number: (760)60Z-8700 <br /> Walgreens#2961 <br /> 75mo�hHamLona ' <br /> Storage Facility Name: <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: 9oouKirby Street, sui*,3uu <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: Dennis M. McComb Title: Pharmacist <br /> 2. Name: Anthony Tran Title: Pharmacist <br /> 3. Name: Joanne M. Garvey Title: Pharmacist <br /> A copy of this exemption and a tracking document while transporting medical waste. maddition,all copies of <br /> medical waste records shall be kept on file at generatoes or health care professional's facility. <br /> Applicant Signature: Guisinay Harris,On behalf of Walgreen,Co. Date: 12/05/2013 <br /> Title: Requlatorv'Compliance Coo(crinator, 3E Company <br /> 0O NOT WRITE BELOW THIS LINE <br /> REHQAp Date: <br /> Expiration Date: Date la? Cash RuoeixodBy: <br /> sxo*5-01am12 APPLICATION FOR ALIMITED QUANTITY HAULING EXEMPTION <br />