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iF p D <br /> oAqu,tnr RSAN JOAQUIN COUNTY <br /> JAN - 9 2012 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Ea 't Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH <br /> r., <br /> (209)468-342,b.Fax: (209)464-0136 Web:www.sjgov,org/ehd PERMIT/SERVICES <br /> 'NQ <br /> 'APPLICATIONFOR ;,LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fora"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 /> 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 Waste Management Plan if the generator or parent organization is a large quantity generator or a <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: <br /> FILE Lupy <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> U New N 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: Lyazzat Segizbayeva Agent for Walgreens Corporation <br /> Phone Number: (760)602-8700 <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: 0 Kirby Street,Suite 300 <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: Bunnaun Uch Title: Pharmacist <br /> 2. Name: Christine Chau Title: Manager/Pharmacist <br /> 3. Name: Uyen Nguyen Title: Pharmacist <br /> 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 <br /> medical waste records shall be kept on Vtg atgenerator's or health care professional's facility. <br /> Applicant Signature: / Date: 12106/2011 <br /> Title: Agent for Walgreens Corpgfation <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval:, Date: CAJ6 /_ <br /> Expiration Date: I Z 1311�Z'Date Paid: I I Cash or Check Received By: _ <br /> EI-1134-5-01 11129!11 APPLICATION FOR A IM17ED QUANTITY HAULING EXEMPTION <br />