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---------- -- - - - ------ - . ' FSECOPY 4 o[7 0 G ,'y sa P11 SAN JOAQUIN COUNTY REC ?oal: ENT ENVIRONMENTAL HEALTH DEPARTMENT FEB _ 7 2011 600 East Main Street,Stockton,CA 95202-3029 div Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd AQUIN CpU �c 6� ►i3OMENTA L EJC APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION i CEPAR-rMEN„r, To qualify for a"Limited Qua QI-I 4i 6mption"pursuant to the"Medical Waste Management Act",the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport less than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with$77.00 fee to: d a San Joaquin County Environmental Health Department 5 Medical Waste Management Program O 3 t 1i 600 East Main Street, Stockton,CA 95202-3029 Medical Waste Hauler Information ®New ❑Renewal Medical Office/Business Name: Walgreens#2961 Medical Office/Business Address: 75 North Ham Lane Lodi CA 95242 City State Zip Code Contact Person: Karina Aguilar,Agent for Walgreens Corporation Phone Number: (760)602-8887 Storage Facility Name: Walgreens#2961 Storage Facility Address: 75 worth Ham Lane Lodi CA 95242 City State Zip Code Permitted Treatment Facility Name: sharps Compliance,Inc. Permitted Treatment Facility Address: 9350 Kirby Street,Suite 300 Houston TX 77054 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: David Loth Title: Pharmacist 2.Name: Dennis McComb Title: Pharmacist 3,Name: Joanne Garvey Title: Manager/Pharmacist 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 medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: _ - Date: 12/0212010 Title: Agent for Walgreens Corporation DO NOT WRITE BELOW THIS LINE R.E.H.S.Application Approval: �k o x Date: x/39 Expiration Date: tl << Date Paid:�/(� I�Cir Check#: Received By: LHp 45-01 1 V19/08