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............. . . . ....... <br /> MAIL <br /> . ........... _.......... .. .. <br /> �e [ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .: 1868 East Hazeiton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMP nON <br /> To qualify for a°Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met: <br /> I. <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 j <br /> small quantity generator required to register pursuant to Chapter 4. <br /> 2. Information Dcaurnent 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: T <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 i <br /> Medical Waste Hauler Information <br /> 0 New A Renewal <br /> Medical OfficelBusiness Name: Walgreens#2434 <br /> Medical Office/Business Address 1830W11thStreet <br /> Tracy CA 95376 <br /> City State Zip Code <br /> Contact Person: Lyazzat Segizbayeva, on behalf of Walgreen Co. _ <br /> Phone Number: (760)602-8637 <br /> Walgreens#2434 I <br /> Storage Facility Name: 1830 W 11th Street <br /> Storage Facility Address: Tracy CA 95376 I <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: Amv Nquven Title: Pharmacist <br /> 2, Name Helen Hilbero Title: Pharmacist <br /> 3. Name: im Balzer 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 f <br /> medical waste records sha4bGfelpn fila at generator's or health care professional's facility.Applicant Signature: Lyazzat Segizbayeva,On behalf of Walgreen Co. Date: 11/26/2012 <br /> Title: Regulatory ComCoordinator, 3E Comnanv <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: _L.V_j /_Z.r <br /> Expiration Date: 1,7>_Date Paid: I%Z l�!�1/vim Cash or he .322. 6 Received By:= . <br /> EHD 45-01 5/2M2APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> i <br />