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r <br /> no 4 2 764920 GL PAYMENTlit <br /> SAN JOAQUIN COUNTY REL' <br /> ENVIRONMENTAL HEALTH DEPARTMENT EIVED <br /> 600 East Main Street,Stockton,CA 95202-3029 FEB _ 7 201 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> SAN JOAQUIN COUN7Y <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOt LTH l""O A TAL <br /> a MENT <br /> ')�ption"pursuant to the"Medical Waste Management Act",the following <br /> To qualify fora"Limited Quantt Q�'a)a i <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transport 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 <br /> or a small quantity generator required to register pursuant to Chapter 4. <br /> 2. h1formation Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. F d O ® •�q� <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program R S 3 6 us l <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ®New p Renewal <br /> Medical OfficeBusiness Name: Walgreens#2434 <br /> Medical Office/Business Address: 1830 W 11th Street <br /> Tracy CA 95376 <br /> City State Zip Code <br /> Contact Person: Karina Aguilar,Agent for Walgreens Corporation <br /> Phone Number: (760)602-8887 <br /> Storage Facility Name: Walgreens#2434 <br /> Storage Facility Address: 1830 W 11th Street <br /> Tracv CA 95376 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Pennitted 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 Nguyen Title: Pharmacist <br /> 3.Name: Desiree Chipman 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 waste. In <br /> addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12/02/2010 <br /> Title: Agent for Walgreens Corpora ion <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: ��,,. � Date: <br /> Expiration Date: Date Paid:�I l_� CaQls Check#: Received By: ^ <br /> EHD 4 5-01 <br /> 11119/08 <br />