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0 01 <br /> San Joaquin County Public Health Servides <br /> Environmentai Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT1 116;' <br /> �r <br /> To qualityfor a "Limited Quantity Hauling Exemption" pursuant to the "Wdicat Waste A-vr e6ig9tAct", the followlag <br /> rnnr0tlnnc Mi mt ha mAt <br /> DATE INVOICE AMOUNT 90-.103/1211 <br /> FREMONT VETERINARY CLINIC <br /> ` 2223 EAST FREMONT STREET l 2 2 G O <br /> PO.BOX 1952 <br /> STOCKTON,CALIFORNIA 95201-1952 <br /> ,IN11 111 �- <br /> TL?E SU P w••,� laril." <br /> , ! is �..,;; <br /> PAY 1 DOLLARS <br /> TIMEGROSS FED. SOC. STATE S D 1 MEDT- NET AMOUNT <br /> K'D' pATA TO THE ORDER OF AMOUNT MIC.TAX SEC. W.T. CARE <br /> FREMONT VETERINARY CLINIC <br /> BANKTCOMMERCIALS VII�GS USTOSTOCKTON,CA f �' <br /> n®0 2 260911' #: 4 2 & 40 hG ?#: 11,e1109 5411111y00 <br /> MQdiqal ftefa Hauler Informatioll <br /> ❑ New EX Renewal <br /> Meq cal Office/Business Name:FREMQNiT VETERINARY CLINIC <br /> Meal Office/Business Ad ess: 2 2 2 3 lla. FR 4MQN ST, P. 0. BQ_C 1052 <br /> City: ,TOCKTnw State:�j, TJp Code: '" t,._____-- <br /> Contact Person: ROBERT LINDSTRO"t# DVM Phone* 209-465-7291 <br /> Storage Facility Name: NA <br /> Storage Facility Address: NA <br /> City: State: Zip Cade: <br /> Permitted Treatment Facility Name: FREMONT VETERINARY <br /> Permitted Treatment Facility Address:2223 El FREMONT ST. P.O. BOX 1952 <br /> City: STQCKT0N State: CAIJE Zip Code: 9ii2n1 <br /> List all employee names and titles authorized to transport lhe,medical waste. If not enough space, attach information, <br /> 1- Name: DR. ROBERT LINDSTRON Title: PARTNER <br /> 2- Name: DE_, TARRY WATERBIJEX �- Title: PARTNER I <br /> 3- Name: Title: <br /> A a ofth'a exem i n da skin u s l lae.in l e 's sees w a l w l e P medical waste. In <br /> i d°i 'nl Ii� i M !iAg i IIS x i 1 p i�'1pr # i� n A " ` ' I� iiA i+ ' <br /> li�ant: i <br /> i <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: / / Expiration Date: / / <br /> EH4502 10-03-96 Date Paid / / Cash or Check # (circle) Acct <br />