COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

f Y s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ng 1868 East Hazelton Avenue, Stockton, CA 95205-6232 fi' • (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd L�ko i APPLICATION FORA LIMITED QUANTITY HAULING EXEMPTION lK, .. I To qualify for a"Limited Quantity Hauling Exemption" 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 j 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 wit�h71�,Q San Joaquin County Environmental Health Department Medical Waste Management Program 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Medical Waste Hauler Information 0 New 9 Renewal Modica] Office/Business game: Walgreens#10454 Medical Office/Business Address 1071 N ain Street Manteca CA 95336 City State Zip Code Contact Person: Lyazzat Segizbayeva, on behalf of Walgreen Co. Phone Number. (760)602-8637 Storage Facility Name: Walgreens#10454- 1071 N Main Street Storage Facility Address: Manteca CA 95336 City state zip Code Permitted Treatment Facility Name: Sharps Compliance, Inc. Permitted Treatment Facility Address: 9350 Klrbv 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: Cvnthia Mar Tile: Pharmacist 2, Name: Eric Ueda Title: Pharmacist 3. Name: Kevin Wonq Title: Pharmacist A copy of this exemption and a tracking document shall he in employee's possession at all times while transporting medical waste. in addition,all copies of medical waste records shall b kept on file at generator's or health care professionars facility, Applicant Signature: Lyazzat Segizbayeva,On behalf of Walgreen Co. pate: 11/26/2012 Title: Requlato Comoli nce Coordinator, 3E ComDany DO NOT WRITE BELOW THIS LINE RENS Application Approval: Date: L21\\ ! 4r2 Expiration Date: Date Paid: l�l/a—Cash ec :,?/o44�6 7 Received Sy_ EHD 45-01 512112 APPLICATION FOR A LIMITED QUANTITY HAULING E EMPTION I