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(` A,T <br /> . . YPAYA# <br /> ` SAN JOAQUIN COUNTY R CE�VEp <br /> ENVIRONMENTAL HEALTH DEPARTMENT EB <br /> �,� :. ....� 2011 <br /> 600 East Main Street,Stockton,CA 95202-3029 SAN <br /> ` r <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web:www.s ov.or ehd EN IROM Cp <br /> P ( ) ( ) .3g �l HEgCTF1 pp�ENTgL" <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION EPgRT1yENT <br /> To qualify for a"Limited QuantigghUk a r ption"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,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 haste 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. Information Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. 1A 6 O a 0 <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Department R U b ?)1644 0\ <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 053 `O S 2 <br /> Medical Waste Hauler Information\ <br /> ®New ❑Renewal <br /> Medical Office/Business Name: Walgreens#10766 <br /> Medical Office/Business Address: 2810 S Tracy Boulevard <br /> Tracy CA 95377 <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#10766 <br /> Storage Facility Address: 2810 S Tracy Boulevard <br /> Tracv CA 95377 <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: Larry Nguyen Title: Pharmacist <br /> 2.Name: Amy Nguyen Title: Manager/Pharmacist <br /> 3.Name: Title: <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 <br /> DO N-�OT_ WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval: `,C�.�-�•� �C� Date: <br /> n -o 00 7G 19 is 1 <br /> Expiration Date: T/ l�Date Paid: / t / ` Cath-er Check#: Received By: <br /> EH45-01 7 <br /> Oil) <br /> 11/19/08 <br />