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M • <br /> o I�I 111 l <br /> SANJOA COUNTY <br /> k JAN — 9 2012 <br /> ENVI40NMENTAL HEALTH DEPARTMENT <br /> 600 E t Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH <br /> (209)468-34 0 Fax: (209)464-0138 Web:www.sjgov.orglehd PERMIT/SERVICES <br /> gC/FOR�� <br /> APPLICATION FOR,,A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exem( ion"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 /> Health De <br /> San Joaquin County Environmental artment p <br /> __Med:bal-Waste Management Program <br /> ---------- ---- <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New 29 Renewal <br /> Medical OfficelBusiness Name: Walgreens#2961 <br /> Medical Office/Business Address 75 North-F[affi----a—ne <br /> Lodi CA 95242 <br /> city State Zip Code <br /> Contact Person: Lyazzat Segizbayeva Agent for Walgreens Corporation <br /> Phone Number. (760)602-8700 <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: 9350 Kirby Street, Suite 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: David Loth Title: Pharmacist <br /> 2. Name: Dennis McComb Title: Pharmacist <br /> 3. Name: Joanne Garvey Title: Manager/Pharmacist <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical wastein addition,all copies of <br /> medical waste records shall be kept on file a rator's or health care professional's facility. <br /> Applicant Signature: Date: 12/06/2011 <br /> MIS � <br /> Title:Agent for Walgreens Corporation <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval• , Date: �l�ltz <br /> Zt���o3Z5Z <br /> Expiration Date: kLI 12k II-L-Date Paid: I 1(Z Cash or Check#: Recceived By: <br /> I=HD 45-0111129111 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />