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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.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> following <br /> ng <br /> conditions must bemet: <br /> T�gen��orh�������ona|ge���less��20 ��m�i�lwas�per w���s ��� | <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the <br /> generator orparent organization has onfile one ofthe following: <br /> i' Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a <br /> small quantity generator required tnregister pursuant bzChapter 4. | <br /> | <br /> 2. Information Document ifthe generator orparent organization is asmall quantity generator not required to <br /> register pursuant toChapter 4. � <br /> Please complete the information below and mail with $7700fee to. <br /> EYm« <br /> San Joaquin County Environmental Health Department <br /> RECEIVED— <br /> Medical � <br /> VVaotaK8anagmmontPnognam � � <br /> 1DG8EaatHaza|ton/4/onue' 8too�on. C/\95205-G2324� / DEC 2 0 20 <br /> Medical Waste Hauler Information <br /> 10AQUIN COOMY <br /> � <br /> F.'"iRONMENTAL <br /> ,,ALTH DEPAMVENr ' <br /> 11 New 9Renewa <br /> - <br /> Medical Qf5ce/BnelnmssName: VVaigreeno#1U4S4 <br /> Medical Address '~' ' '~~~' '`~~^ ~~~~^ <br /> Manteca CA 95336-3744 <br /> .City State Zip Code <br /> Contact Person: | <br /> Phone Number: <br /> Walgreens#10454 <br /> 1o71 No���oinGma,g <br /> Storage Facility Name: ' <br /> Storage Facility Address: Manteca C" <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Addremz 9350 Kirby <br /> Houston TX <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: K8nnda<3.Tien Title: Pharmacist <br /> 2' Name: KjrstioJ. Yi Title: Pharmacist <br /> 3. Name: uanooapGm Title: Pharmacist <br /> A copy of this exemption I and a tracking document shall be In employee's possession at all times while transporting medical waste. In addition,all copies m <br /> medical waste records shall be kept on file at generatoes or health care professional's fac[14. <br /> Date� 12/05/2013 <br /> Applicant Signature:- -Title: Re.qulatory Compliance Coordinator, 3E Comr)anv <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: 42-IA-11a <br /> 111 -4 i /I Date Paid: Cash oi�-�eck J��3r Received By: <br /> Expiration Date: <br /> FHD 45-015012 mPPuuxnowroR ALIMITED QUANTITY xAuuwoEXEMPTION <br />