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,oP``� '"•.ca SAN JOAQUIN COUNTY <br /> E.IIRONMENTAL HEALTH DEPARTIONT <br /> y 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> «. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web www.sjgov.org/ehti' <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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, transport 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 <br /> or a 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 <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$70.00 fee to: <br /> San Joaquin County Environmental Health Department PAYf�, =NT <br /> Medical Waste Management Program REC`" VE;) <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 <br /> -NOV 2 9 204 <br /> Medical . Waste Hauler Information <br /> SAN JUnrMiN C('1—TY <br /> p New Ki Renewal ENvr 'AME" <br /> HEALTH uEPAR .—NT <br /> Medical Office/Business Name: FREMONT VETERINARY CLINIC <br /> Medical Office/Business Address: 2223 E. FREMONT ST. <br /> STOCKTON, CALIF. 99205 <br /> City State Zip Code <br /> Contact Person: RnRF.RT T TNT)STRnm <br /> Phone Number: 209-465-7291 <br /> Storage Facility Name: FREMONT VETERINARY CLINIC <br /> Storage Facility Address: 2223 E. FREMONT ST. <br /> STOCKTON., CAI,TP. �35?Q5 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: STERICYCLE, INC. <br /> Permitted Treatment Facility Address: 28161 N. KEITH DR. <br /> LAKE FOREST IL. 60045 <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: ROBERT LINDSTROM DVM Title: PARTNER <br /> 2. Name: LARRY WATERBU&yRVM Title: PARTNER <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste r r Is shall be kept on file at generator's or health care professional's facility. <br /> '` . <br /> Applicant Signature: ��/ZGz/ �i2iL Date:11-24-04. <br /> Title: PARTNER <br /> DOXN/n <br /> T WR �T ELOW THIS LINE <br /> R.E.H.S. Application Approval: ti Date: <br /> Expiration Date: _1�7_ /_51 /OSDate Paid: Cash or Check#: JY-7 7 Received By: ��T• <br /> EHD 45-02-001 <br /> 10/7/2003 <br />