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VLU <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 96205-6232 <br /> (209)468-3420 Fax:(209)464-0138 Web:www.sigov,orglehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant bothe"Medical Waste Management 8of.the following <br /> conditions must bmmet: ! <br /> The generator orhealth care professional generates less than 2O 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 Waste Management Plan if the generator orparent organization imolarge quantity generator oro | <br /> small quantity generator required toregister pursuant toChapter 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 /> Please complete the information below and maiUwi th$77.00 fee t <br /> San Joaquin County Environmental Health OmpartmentAP m'"-«^ 2 � <br /> �Nodioo|\�oobeyWonogernentProgram �� - s^» /n^vv=couNTr <br /> Qpj <br /> ~~.^ ^"p�AL <br /> 1888EaotHaze|tun/�enue. Gtoc�on. CAS52O5-G232 ^LAL,H JF'P~prwENT <br /> Medicat Waste Hauler Informatlon <br /> ` <br /> ONew @QRenewal <br /> - . <br /> Medical � Name: Walgreens#10766 <br /> Medical Office/Business Address -2810 Sout 'Tracy <br /> Tracv CA 95376 <br /> City State Zip Code <br /> Contact Person: Gulsinay Harris, On behalf of Walcireen. Co. <br /> Phone Number: (760)602-8700 <br /> ' <br /> Walgreens#10766 <br /> Storage Facility Name: 2810 South Tracy Blvd. <br /> Storage Facility Address: Tracy CA 95376 <br /> city State Lip Code. <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: 9350 Kirby S reet, 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: Christine Chan Title: Pharmacist <br /> 2. Noma: Tarry Nguyen Title: Pharmacist <br /> 3. Name: Craiq J. Lewandowski Title: Pharmacist <br /> A copy ofmm exemption andatracking uvcument shall be In employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall uekept vnfile atgenerator's o,health care professional's facility. <br /> AooU � /�/^ Dote: 12/05/2013 <br /> Title: <br /> DO NOT WRITE BELOW THIS LI N E <br /> REH@Application Approval: <br /> Expiration Date: Du����� Cash R�uo�ad�� <br /> sxo*5-01smnx APPLICATION FOR ALIMITED QUANTITY HAULING EXEMPTION <br />