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ROW <br /> of _iN• c SAN JOAQ IN COUNTY ` <br /> _ ENVIRONMENTAL HEALTH DEPARTMENT ? i <br /> ��'• :- :a <br /> '. 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> 8-3420 Fax: 209 464-0138 Web:www.sjgov.orglehd <br /> (209)46 ( } <br /> APPLICATION FORA LIMITED QUANTITY H4ULINO EXEMPTION I i <br /> To qualify for a'Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act',the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transports less <br /> , l <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the I <br /> generator or parent organization has on file one of the following: <br /> 1. 'Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a <br /> 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 /> Please complete the information below and mail with $77.00 fee to: I <br /> San Joaquin County Environmental Health Department "P'D <br /> Medical Waste Management Program OZ <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 <br /> Medleal Waste Hauler l format10n <br /> 0 New N Renewal <br /> Medical OfficelBusiness Name: Walgreens#10482 <br /> Medical Office/Business Address 7850 West Lane <br /> Stockton CA 95210 <br /> city State Zip Code <br /> Lyazzat Segizbayeva,on behalf of Walgreen Co 1 <br /> Contact Person: (760)602-8631 <br /> Phone Number. - <br /> Walgreens#10482 <br /> Storage Facility Name: 7850 West Lane <br /> 210 <br /> Storage Facility Address: Stockton CA <br /> City State Zipp Coda <br /> od <br /> Permitted Treatment Facility Name: Sharps Compliance, Inc. <br /> Permitted Treatment Facility Address: 9350 Klrbv Street. Suite 300 <br /> HoustonTX 7705 _ <br /> City _. State Zip Code l <br /> I <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1. Name: An Nauven Title: Pharmacist ; <br /> 2, Name: Christine Chau _ 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,all copies of <br /> medical waste records shall be pt on file at generator's or health care professional's facility. <br /> Lyazzat Segizbayeva,on behalf of Walgreen Co. Date: 11/26/2012 <br /> Applicant Signature: <br /> Title: Regulatory Com Iia e Coordinator. 3E Co an <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: bate: !:ii A <br /> Expiration Date: 1'1 / Date Paid: �Z!dv 1/-2-C2sh or he : Received By: <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> EHD 45-015/2112 <br />