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oAa4tl+v •o SAN JOAQUIN COUNTY '••' '•• .� JAN - 9 2012 ENVIRONMENTAL HEALTH DEPARTMENT { 600 E .t Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH (209)468-344 Fax: (209)464-0138 Web:www.sjgov.org/ehd PERMIT/SERVICES ORS n, APPLICATION FOR 4 LIMITED QUANTITY HAULING EXEMPTION To qualify for a"LimitedQuantity Hauling Exemon"pursuant to the"Medical Waste Management Act",the following conditions must bd 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 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 Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information ❑ New A Renewal Medical Office/Business Name: Walgreens#10631 Medical Office/Business Address 14780 Harlan Road Lathrop CA 95330 City State Zip Code Contact Person: Lyazzat Segizbayeva Agent for Walgreens Corporation Phone Number. (760)602-8700 Walgreens#10631 Storage Facility Name: 14780 Harlan Road Storage Facility Address: Lathrop CA 95330 City State Zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment Facility Address 9 Houston ston Kirby Street Suite 300 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: Mark Sakata Title: Pharmacist 2. Name: Danllo Padilla Title: Pharmacist 3. Name: Kien Quach Title: Manager/Pharmacist 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 kep n file at generator's or healthcare professional's facility. Applicant Signature: L`?{ Date: 12/06/2011 Title: Agent for Walgreens.Qrporation DO NOT WRITE BELOW THIS LINE REHS Application Approval: , d - ,� __ Date: nt�le�,�( l Expiration Date: �Z'1 '9 11 Z. Date Paid: I /%/ ►Z- Cash or Check#?��3'0t�ece ed By:.��'�S____ EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION