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4 i~ IE91PY R AYIVIENT 00 0 0;2 7 . 8 a,i ECEIVED SAN JOAQUIN COUNTY 4" �y ENVIRONMENTAL HEALTH DEPARTMENT FEB 7 Zoll 600 East Main Street Stockton,CA 95202-3029 SAN�OAQUI Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd HEq�N�RnOMEN ALN1Y c EPARTIN�M APPLICATION FOR�A�LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity{ giiir ;l �ih�ion"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 Waste Mm7agement 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. O ® .2- 0 &q Please complete the information below and mail with$77.00 fee to: San Joaquin County Environmental Health Department b 5 3 142 0 4 Medical Waste Management Program 600 East Main Street,Stockton,CA 95202-3029 6 b k L 2-L� Medical Waste Hauler Information ®New ❑Renewal Medical Office/Business Name: Walgreens#4343 Medical Office/Business Address: 29 E March Lane Stockton CA 95207 City State Zip Code Contact Person: Karina Aguilar,Agent for Walgreens Corporation Phone Number: (760)602-8887 Storage Facility Name: Walgreens#4343 Storage Facility Address: 29 E March Lane Stockton CA 95207 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: Debra Short Title: Manager/Pharmacist 2.Name: Maria-Jocely Gayagoy Title: Pharmacist 3.Name: An Nguyen Title: 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 kept on file at generator's or health care professional's facility. Applicant Signature: e f f _ Date: 12/02/2010 Title: Agent for Walgreens Corporation DO NOT WR TE BELOW THIS LINE R.E.H.S. Application Approval: _ Date: / 3 / Expiration Date: I'Z Al l / tI Date Paid: Check#: Received By: �rrr DID 45-01 11/19/08