COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

'' o p i SAN JOAQUIN COUNTY 2' —` 'Z ENVIR6NMENTAL HEALTH DEPARTMENT JAN - 9 2012 . ` :. 600 Eat Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH ...., (209)468-342Q Fax: (209)464-0138 Web:www.sjgov.org/ehd PERMIT/SERVICES APPLICATION FOR LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exemoion"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 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. Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department � Medical Waste Management Program .ice 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information ❑ New 9 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: Lvazzat Segizbayeva.Agent for Walgreens CQrporation 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: 93EO 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: Patrick Meneses Title: Pharmacist 2. Name: Helen Spencer Title: Manager/Pharmacist 3. Name: Michael Giovannoni 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 gen roto s or health care professional's facility. Applicant Signature: `�/../ Date: 12/06/2011 Title: Agent for Walareens Corporation DO NOT WRITE BELOW THIS LINE REHS Application Approval, ��qn. �� Dater/ Expiration Date: ZI/ ✓'/ Date Paid: / I / Cash or Check#:Z VCO 50R� ivd By: EHO 454111/28111 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION