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P t0�72 7o , PAY N JOAQUIN COUNTY '$ COPY RECE,VNT j ° '' ENVIRONMENTAL HEALTH DEPAI T E 600 East Main Street,Stockton,CA 95202-3029 FEB '- 7 2011 Telephone:(209)468-3420 Fru:(209)468-3433 Web:www.sjgov.org/ehd SAN JOO ENVAOUIN COUNTY APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTItAETH E ATAAENT To qualify for a"Limited Quanti �yj ji'W6ption"pursuant to the"Medical Waste Management Act",the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport 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 TVaste 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. PIease complete the information below and mail with$77.00 fee to: �- G b 5 3 San Joaquin County Environmental Health Department b O 3 2� 3 Medical Waste Management Program 600 East Main Street,Stockton,CA 95202-3029 65 A�5 Medical Waste Hauler Information ®New ❑RenewaI Medical Office/Business Natne: Walgreens#10454 Medical Off ceBusiness Address: 1071 N Main Street Manteca CA 95336 City State Zip Code Contact Person: Karina Aguilar,Agent for Walgreens Corporation Phone Number: (760)602-8887 Storage Facility Name: Walgreens#10454 Storage Facility Address: 1071 N Main Street Manteca CA 95336 City State Zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment facility Address: 9350 Kirby Street,Suite 300 Houston 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: Anne Engdahl Title: Manager/Pharmacist 2.Name: Andrea Bartels Title: Pharmacist 3.Name: Title: 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 kept on file at generator's or health care professional's facility. Applicant Signature: 11�- ec -"` Date: 12/02/2010 Title: Agent for Walgreens Corporation DO NOT WRITE BELOW THIS LINE R.E.H.S.Application Approval: , �.C "�- Date: -2-1fil 9 -�� l�� Expiration Date:��/ L /�� Date Paid:�/ � / �� eek1,-#:ono 2gb R'eceived 13y: EHD 45-01 11119108