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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> -6232 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205 <br /> (209)469-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for s"Limited Quantity Hauling Exemption"pursuant buthe"Medical Waste Management Acf. the following . <br /> conditions must bomet <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 orparent organization has onfile one ofthe following: <br /> 1. Medical � i Management Plan if the generator or parent organization is a large quantity generator or a � <br /> | <br /> small quantity generator required boregister pursuant tmChapter 4. ' <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant toChapter 4. <br /> MENT <br /> Please complete the information below and mail with$77 00 fee to: | <br /> /�� / K��� � � ��8 <br /> SanJoaquin County Em�ronnnmnt | Rma�hDeparbnent APPROVE ��� ~ ~~-~ <br /> Medical Waste Management Pmgram ` <br /> 1888East Hazelton Avenue, Stockton, C/\A52O5-G232 xE==~~~^~^~EALTH ~r <br /> `-^ Medical Waste Hauler Information ' <br /> ONew KRenewal <br /> ' VVo| #2434 - <br /> K0md���]offYcm/Bumhm*am@amne: <br /> Medical Office/Business Address -T830 West 11"' Street <br /> Tracy CA 95376 <br /> cnv State "p°""" <br /> Contact Person: Gulsinay Harris, On behalf of Walgreen, Co. <br /> .Phone Number: (760)602-8700 <br /> Walgreens#2434 <br /> Storage Facility Name: 1830 <br /> West 11 th Street <br /> Storage Facility Address: Tracy <br /> ip Code <br /> city State -7 <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: 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: Helen M. Hilbero Title: Pharmacist <br /> 2. Name: Amy U. Nquyen Title: Pharmacist <br /> 3.Name: Jim L. Balser Title: <br /> 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 <br /> medical waste records shall be kept on file at generatoes or health care professional's facility. <br /> AppU Date: 12/O5/2O13 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> ~�' � <br /> REHGApApplication � jZ <br /> Expiration Date: ' Date Paid: ^"=. `,~.~,..By:-4=�~___ <br /> Exo45-01e211c APPLICATION FOR xLIMITED QUANTITY HAULING EXEMPTION <br />