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.-C SAN JOAQUIN COUNTY <br /> W- ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax. (209)464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> ! <br /> To qualifyfor a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act', the following <br /> conditions must bamet:The generator or health care ' <br /> ' | <br /> professional generates less than 20 poundsofmedical waste per week,transports|eon <br /> than 2Opounds ofmedical waste mtany one time, maintains a tracking document pursuant aoChapter uand the <br /> generator orparent organization has onfile one ofthe following: | <br /> � <br /> 1' Medical Waste Management Plan ifthe generator orpmmxntorganizoUonkae|argaquanUtygeneraturora <br /> small quantity generator required horegister pursuant tuChapter 4. i <br /> � <br /> 2. Information Document if the generator or parent organizabon is a small quantity generator not required to <br /> register pursuant bnChapter 4 <br /> Please complete the information below and mail with $77.00 fee to: C'VVEO <br /> DEC I <br /> ~~'^~~~,—^ ---'y—'''---ntal—Health— Department APP <br /> ROVEMIN <br /> Medical Waste Management Program <br /> 18S8East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ~ '_ <br /> Medical Waste Hauler Informatlon <br /> O New XRenewa| <br /> Walgreens#10482 <br /> ` <br /> Medical �ao�e ' <br /> Medical Address 'obv West Lw/m, <br /> Stockton CA 95210 <br /> city State Zip Code <br /> Contact Person: Gulsinay Harris, On behalf of Walareen, Co. <br /> Phone Number: (760)602-8700 <br /> ' Walgreens#1o400 <br /> 'oouWest Lane <br /> Storage Facility Name: <br /> Storage Facility Address: omuxm// <br /> CA 95210 <br /> ity State Zip Code. <br /> PermittedO� 8harpnCnmp|iance <br /> �rem�omnt�a� <br /> Facility ' Inc. <br /> Permitted Treatment Facility Address: ~~~~ '^''~, ~^'~~^' ~~'~ ~~~ ' <br /> Houston TX 77054 <br /> city State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(if more than 3, attach info): <br /> 1. Name: An p Nquven Tide: Pharmacist <br /> 2. Name: Vivian Lee Title: Pharmacist <br /> 3. Name: 'Christine Chau Title: Pharmacist <br /> A copy of this exemption and a tracking document shall be In empioyeals mtall times while transporting medical waste. maddition,all copies m <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> ' AooU Date: 12/05/2013 <br /> Title: Comoliance Coordinator, 3E Company <br /> 0O NOT WRITE BELOW THIS LINE <br /> | <br /> REH8Application App ) <br /> Expiration Date: Date Paid: conn 411,51 /necewevBv._��_�=�_ <br /> ! Exo45-01 512J12 xppuCAmLIMITED <br /> � <br /> � <br />