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.. ._.. .. .... .. .. I Jls �/ Z °t'6�iM'•°.0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 17 I (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd 7 APPLICATION FORA LIMITED QUANTITY HAULING EXEMPTION To qualify for a'Limited Quantity Hauling Exemption" 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, transports less than 20 pounds of medical waste at any one tilrle,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. f San Joaquin County Environmental Health Department Medical Waste Management Program 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Medical Waste Hauler Information 0 New N Renewal Medical OfficelBusiness Name: Walgreens#10766 Medical Office/Business Address 2 10 S Tracy Boulevard racy CA 95377 City State Zip Code Contact Person: Lyazzat Segizbayeva, on behalf of Walgreen Co. Phone Number. (760)602-8637 Walgreens#10766 Storage Facility Name: 2810 S Tracy Boulevard Storage Facility Address: Tracy CA 95377 City State Zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment Facility Address: 935 Irby 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: Christine Chan Title: Pharmacist 2. Name: Larry Nguyen Title: Pharmacist I 3. Name: Song Vanq Title: Pharmacist A copy of this exemption and a tracking document shall be in employee's possesslon at all times while transporting medical waste. In addition,all copies of medical waste records shalt be ke ton file at generator's or health care professional's facility. I Applicant Signature: Lyazzat Segizbayeva,On behalf of Walgreen Co, Date: 11/26/2012 Title: Regulatory Complia Ce Coordinator, 3E Comoanv DO NOT WRITE BELOW THIS LINE REHS Applicabon Approval: �_ \ _ ti Date: _11;•�/�v Expiration Date: /Sj/15_Date Paid: /-I I/,,1-Cash or 4 Received€3y: EHD 45-015012 APPLICATION FOR A UNITED QUANTITY HAULING EXEMPTION