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° 4o U1N COUNTYH <br /> l` <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Nit <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 <br /> .�`4•.-= (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 1 <br /> «sem <br /> APPLICATION FORA LIMITED QUANTITY HAULING EXEMPTION <br /> :•5 <br /> I <br /> To qualify for a'Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act',the following <br /> conditions must be met: f <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transports less <br /> i <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the following: <br /> 1. Medical baste Management Plan if the generator or parent organization is a large quantity generator or a i <br /> small quantity generator required to register pursuant to Chapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required to ' <br /> register pursuant to Chapter 4. <br /> I <br /> ' I <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department lJ ry�^� . <br /> Medical Waste Management Program r <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-5232 1 <br /> Medleal Waste Hauler I formation <br /> 0 New 0 Renewal <br /> Medical Office/Business Name: Walgreens#10482 <br /> Medical Office/Business Address 7850 West Lane <br /> Stockton CA 95210 <br /> city state zip code <br /> Contact Person: (760) <br /> Segizbayeva, on behalf of Walgreen Co <br /> Phone Number: -(760)602-8637 <br /> Walgreens#10482 <br /> Storage Facility Name: 7850 West Lane <br /> Storage Facility Address: Stockton CA 95210 <br /> City state Zip Code <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: 35 Klrbv Street. Suite 300 <br /> Houston TX 77054 <br /> City State Zip Code <br /> List all employee names and titles authorizes{to transport the medical waste (If more than 3,attach info): <br /> 1. Name: An Nquven Title: Pharmacist <br /> 2. Name: Christine Chau <br /> Title: Manager/Pharmacist <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shalt be In employee's possession at all times while transporting medical waste. In addition,ail coples of <br /> medical waste records sha&,konfine at generator'sor health care professional's facility. <br /> Applicant Signature: yazzat Segizbayeva,On behalf of Walgreen Co. Date: 11/26/2012 <br /> Title: RedulatoryComrdinator 3E Company <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: -- � 1A, Date: <br /> Expiration Date: Date Paid: �� I J 1 Cash or he 21311' Received By:—� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> EHD 45-016/21112 <br />