COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY X ENVIRONMENTAL HEALTH DEPARTMENT • 1868 East Hazelton Avenue, Stockton,CA 95205-6232 (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a'Limited Quantity Hauling Exemption"pursuantto 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,transports 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 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. r --PA YMENT Please complete the information below and mail with$77.00 fee to, San Joaquin County Environmental Health Department APPROVV" --AMC 2 0-2W 11PTIll § Medical Waste Management Program &kN JOAQM COCKY 1868 East Hazelton Avenue, Stockton, CA 95205-6232 EWRONMWTAL 14447 HEALTH DEPAMWENr Medlcall Waste Hauler Information D New K Renewal Medical Office/Business Name: Walgreens#2645 Medical Office/Business Address 678 N. Wilson Way, Suite 15 Stockton CA 95205 City -State- Zip Code Contact Person: GulltMy'Harris, On behalf of Walgreen, Co. Phone Number: (760)602-8700 Walgreens#2645 Storage Facility Name, 678 N.Wilson Way,Suite 15 Storage Facility Address: Stockton CA 95205 City State Zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment Facility Address: '9�5iry 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: Desiree Chipman Title: Pharmacist 2. Name: -P—afr—ick—J.—K-4—eneses 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 generators or health care professional's facility. Applicant Signature: p% Gulsinay Harris,On behalf of Walgreen,Co. Date: 12/05/2013 Title: Re.qulatory Compliance Coordinator, 3E Company DO NOT WRITE BELOW THIS LINE REHS Application Approval: , (.�L— Date: .24 APO Expiration Date: 1,4'51 Date Paid: I.?1,gQIn cash o �ck��Received By: EHD 45-015012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION