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....... .......... . ... - ............ SAN JOAQUIN COUNTY � ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton,CA 95205-62321 I {209)468-3420 Fax; (209)464-0138 Web:www.sjgov.org/ehd "`I yk� APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION d � I To qualify for a'Limited Quantity Hauling Exemption"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,transports less than 20 pounds of medical waste at any one tl'me, 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. i 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with$77.00 fee to: San Joaquin County Environmental Health DepartmentA.PPROV Medical Waste Management Program 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Medical Waste Hauler Informations 0 New ®Renewal Medical Office/Business Name: Walgreens#2645 Medical Office/Business Address 6 N Wilson Way, Suite 15 Stockton CA 95205 city State Zip Code Contact Person: Lyazzat Segizbayeva on behalf of Walqreen Co. Phone Number: (760)602-8637 Walgreens#2645 Storage Facility Name: 678 N Wilson Way Suite 15 Storage Facility Address. Stockton CA 95205 cityState Zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment Facility Address:. I y Street, uite 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: a rlc 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 a ypt on file at generator's or health care professional's facility, Applicant Signature: Lyazzat Segizbayeva,On behalf of Walgreen Co. Date: 11/26/2012 Title: Regulatory Comlin—ce oordina 3E Cornuany DO NOT WRITE BELOW THIS LINE REHS Application Approval: ��•� bate: i Expiration Date: / � Date Paid:�tI�a� Cash or he 3G37GYily Received By:Z EHD 45-01 5/2112 APPL:CATION FORA LIMITED QUANTITY HAULING EXEMPTION i