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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> so <br /> APPLICATION FORA LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for m"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following | <br /> conditions must bemet: � <br /> The generator ochealth care professional generates less than 2O poundsofmedical waste per week, transports less <br /> than 2Opounds cfmedical waste mtany one time, maintains otracking document pursuant toChapter Gand the | <br /> generator nrparent organization has.onfile one ofthe following: . <br /> 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a <br /> small quantity generator required horegister pursuant hoChapter 4. | <br /> 2. Information Document ifthe generator or parent organization iemsmall quantity generator not required to � <br /> register pursuant bzChapter 4. <br /> ENT <br /> Please <br /> � <br /> Please cmmplete the information below and mail with$77' il CEIVED <br /> San Joaquin County Environmental Health Department A ~ — DEC = <br /> 0 2M3 <br /> Medk�|Vaa�NanagementPmgrem �w� <br /> 1�OEa�Ha��nA�nue' S�u��.CAQ�O��� <br /> ' <br /> NiAEWAL <br /> HEALTH <br /> Medical Waste Hauler Information <br /> O New K Renewal | <br /> Medical Qff|cm/BuainesmName: Walgreens#10631 <br /> Medical Offioe/BuoineoyAddress /*'ovHarlan Road <br /> Lathrop CA 95330-9719 <br /> `~y State -- -_- <br /> ContactPareon: Gulsinav Harris, On behalf of Walareen, Co. <br /> Phone Number: (760)602-8700 <br /> Walgreens#10631 <br /> 14780HadanRoad <br /> Storage Facility Name: <br /> Storage Facility Address: Lathrop CA 95330-9719 <br /> city state Zip Code <br /> Peomb±edTreatment Faoi�tyNan�a: Sharps" Compliance,"''' |i Inc. <br /> Permitted Treatment Facility Address: "^^" '~'" <br /> Houston TX 77054 <br /> City State Zip Code <br /> List all emokoveenames and�t�ao�hor�mdbo�onopm�the medical waste 0fmore than 3. a�oohinfo\: <br /> 1.'N nna: DaniKuF. Padilla Tide: Pharmacist <br /> 2. Name: Sonq SonVanq Title: Pharmacist <br /> 2 Nome: Title: <br /> A copy of this exemption and while transporting medical waste. maddition,all copies of <br /> medical waste records_shall—'—kept _~--- professional's facility.` <br /> Guisinay Harris,On behalf of Walgreen,Co. Date: 12/05/2013 <br /> Applicant Signature: <br /> 00NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: -11�ZLIILL <br /> ExpirationDate: 11/5'11 A Date Paid: 1,;�-/-V It Cash o(]��:M Received By:,.& <br /> s*ow5-0na/211z ^PPu �u^ owFOR ALIMITED QUANTITY HAULING EXEMPTION' <br />