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i <br /> 4 <br /> Op4tulN, 9i': SAN JOAQUIN COUNTY G ` <br /> ENVIRNMENTAL HEALTH DEPARTMENT SAN - 9 2012 <br /> 600 E4pt Main Street, Stockton, CA 95202-3029 <br /> .p (209)468-346 Fax: (209)464-0138 Web:www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> APPLICATION FORS LIMITED QUANTITY HAULING EXEMPTIO�f <br /> To qualify for a"Limited.Quantity Hauling Exemolon" 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,transports 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 or a <br /> 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 to <br /> register pursuant to.Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental Health Departmentx ,. <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New N Renewal <br /> Medical Office/Business Name: Walgreens#10454 <br /> Medical Office/Business Address 1071 N Main Street <br /> Manteca CA 9536 <br /> City State Zip Code <br /> Contact Person: Lyazzat Segizbayeva,Agent for Walgreens Corporation <br /> Phone Number. 602-5700 <br /> Walgreens#10454 <br /> Storage Facility Name: 1071 N Main Street <br /> Storage Facility Address: Manteca CA 95336 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: 9350 Kirby Street, Suite 300 <br /> Houston TX 77054 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: Anne Enadahl Title: Manaaer/Pharmsciot <br /> 2. Name: An rea Bartels Title: Pharmacist <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be In employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on file$t 0 ratoes or health care professionars facility. <br /> Applicant Signature: l//�ri/' Date: 12/06/2011 <br /> Title:Agent for Walgreens Cor ora idn <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: �, �„1.� ..,,r Date: c,,i <br /> Z5Z <br /> Expiration Date: ��/ ?21/�LDate Paid: t /�/ IL Cash or Chack#:Zb";3URe3ceived By: <br /> EHO 45-0111/29111 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />