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�II D D <br /> 111", SAN JOAQUIN COUNTY JAN <br /> ENVIRONMENTAL HEALTH DEPARTMENT _ S 2O1Z <br /> N;. .... '{ 600 EaMain Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH <br /> "' PERMIT SERVICES <br /> (209)468-34241 Fax: (209)464-0138 Web:www.sjgov.org/ehd PERMIT/ <br /> SERVICES <br /> FOR A;kLIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exempt n.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 /> a J , <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New ® Renewal <br /> Medical Office/Business Name: Walgreens#2434 <br /> Medical Office/Business Address 1830 W 11th Street <br /> Tracy CA 85376 <br /> City State Zip Code <br /> Contact Person: Lyazzat Segizbayeva,Agent for Walgreens Corporation <br /> Phone Number: (760)602-8700 <br /> Walgreens#2434 <br /> Storage Facility Name: 1830 W 11th Street <br /> Storage Facility Address: Tracy CA 95376 <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: Jim Balzer Title: Pharmacist <br /> 2. Name: Hanh Nquyen Title: Pharmacist <br /> 3, Name: Desiree Chipman Title: Manager/Pharmacist <br /> A copy of this exemption and a tracking documentshall 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 generator's or health care professional's facility. <br /> Il" <br /> Applicant Signature: (/ Date: 12/05/2011 <br /> Title:Agent for Walgreens Comoration <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval:—2-91 ;, .e 9 _ Date: ,tel lI,--) <br /> G� 7 35Z <br /> Expiration Date: Z/��/ II L Date Paid: / (C�Cash or Check#:7-t " 30ReZceived By: <br /> EHD 45-01 11/29111 APPLICATION FOR A IMn ED QUANTITY HAULING EXEMPTION <br />