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I F �.._... .. _.._ .---...... . .. . F„k o :•s SAN JOAQUIN COUNTY P� ,. � EVRONMENTAL HEALTH DEPARTMENT W.” IA 1868 East Hazelton Avenue, Stockton, CA 95205-6232 (209)468-3420 Fax: (209)464-0138 Web:www.stgov.org/ehd i kog�' Al APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION s:r4 w�l To qualify for a'Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act",the following conditions must be mei: 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 tithe, 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 Flan 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$77.00 fee to: San.Joaquin County Environmental Health Department WPROV Medical Waste Management Program 1868 East Hazelton Avenue,Stockton, CA 95205-6232 ' Medical Waste Hauler Information ❑ New N Renewal Medical OfficelBusiness Name: Walgreens#10631 Medical Office/Business Address 14780 Harlan Road Lathrop CA 95330 City State Zip Code Contact Person: Lyazzat Segizbayeva, on behalf of Walgreen Co. Phone Number: (760)602-8637 Walgreens#10631 Storage Facility Name: 14780 Harlan Road Storage Facility Address: Lathrop CA _ 95330 g City State Zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment Facility Address: 9350 KirEy-jtreet, uite 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: Calvin Matsumoto Title: Pharmacist' 2, Name: .Danilo Padilla Title: Pharmacist 3. Name: Jennifer Solari^ Title: Pharmacist i A copy of this exemption and attacking documentshau be in employee's possession at all times while transporting medical waste. In addition,ail copies of medical waste records shall bQ tce on file at generator's or health care professional's facility. Applicant Signature: 1 Lyazzat Segizbayeva,On behalf of Walgreen Co. Date: 11/26/2012 Title: Requlatory Comolian,�e Coordinator 3E Comoanv DO NOT WRITE BELOW THIS LINE RENS Application Approval:�l �-�- N�� Date: X111 1je Ex iration Date: ! 1 Date Paid:�e?! `�//;--C ash or Ile :3f Z� Received By: p .1��1� EIiD 45-01612/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION