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�i .MIS: p Quay otN c (I' SAN JOAQUIN COUNTY ,. :..o JAN — 2' ENVIfNMENTAL HEALTH DEPARTMENT 9 Z��Z �. 600 Main Street,Stockton, CA 95202-3029 ENVIRONMENT (209)468-340 Fax: (209)464-0138 Web:www.sjgov.org/ehd PERMIT/SERVICES TH 9�tF0�� APPLICATION FOR'J�, LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exempifion"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 time, 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 registef 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 $77.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 1. 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information O New N Renewal Medical Office/Business Name: Walgreens#10766 Medical Office/Business Address 2810 S Tracy Boulevard Tracy CA 95377 City State Zip Code Contact Person: Lyazzat Segizbayeva Agent for Walgreens Corporation Phone Number: (760)602-8700 Walgreens#10766 Storage Facility Name: 2810 S Tracy Boulevard Storage Facility Address: Tracy CA 9r 73 7 _ City State Zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment Facility Address: 9350 Kirby Street, Suite 300 Houston TX 77054 City - State Zip Code List all employee nmes and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: carry Nguyen Title: Pharmacist 2. Name: Amy Nguyen Title: Manager/Pharmacist 3. Name: Title: 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 medical waste records shall be kept on fileg4enerators or health care professionars facility. Applicant Signature: Date: 12/06/2011 Title:Agent for Walgreens Cor or ion DO NOT WRITE BELOW THIS LINE REHS Application Approval: ^-- Date:`fit/pgl� i 7.(n0oo33o Z5Z Expiration Date: 12/ (! Z Date Paid: f I �LCash or Check#: eceived By:._� EHD 4561 i i/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION