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4 FILE <br /> TOA UIN <br /> PAYMENT <br /> °"" ''c AN COUNTY <br /> n Q RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> FEB — 7 2011 <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> ..;� Telephone:(209)468-3420 Fru.(209)468-3433 Web:www.sjgov.org/ehd SAN JOAQUIN COUNTY <br /> �c i�'o `i ENVIROMENTAL <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTVWT11 DEPARTMENT <br /> To qualify for a"Limited QuanQ i�aW4ption"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 Waste 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. <br /> Please complete the information below and mail with$77.00 fee to: I 1t () ® \ % q b 1 <br /> San Joaquin County Environmental Health Department fA-Q� U b 3 35 2 2— <br /> Medical <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 l)S 3 6 0 5 <br /> Medical Waste Hauler Information <br /> X1 New p Renewal <br /> Medical Office/Business Name: Walgreens#10482 <br /> Medical Office/Business Address: 7850 West Lane <br /> Stockton CA 95210 <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#10482 <br /> Storage Facility Address: 7850 West Lane <br /> Stockton CA 95210 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Pennitted 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: Bunnaun Uch Title: Pharmacist <br /> 2.Name: Christine Chau Title: Manager/Pharmacist <br /> 3.Name: Uyen Nguyen Title: Pharmacist <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:. 0- ---"'J Date: 12/02/2010 <br /> Title: Agent for Walgreens Corporation <br /> DO NOT WR TE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: I/�/ ( <br /> t n -4 e o 2-111 71 '1 6 \ <br /> Expiration Date: (Z, Date Paid: C�askcu.Check#: Received By: <br /> EHD 45.01 <br /> 11/19/08 A, _)J4�2_;�--/ <br />