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a "!'.�o SAN JOAQUIN COUNTY <br /> y` A&P-01` 1, ENTAL HEALTH DEPARQNT <br /> 304 East Weber Avenue, Yd Floor, Stockton,CA 95202-2708 <br /> ■ �:, P• (209)468-3420■Fax:(209)468-3433 • ii'eb:www.cosan joaquin.ca.us/ehd <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. PAYMENT <br /> Please complete the information below and mail with$70.00 fee to: RECEIVED <br /> San Joaquin County Environmental Health Department DEC 12003 <br /> Medical Waste Management Program <br /> UNTY <br /> 304 East Weber Avenue, 3`A Floor, Stockton, CA 95202 SAENVVIIRONM NAQUIN OTAL <br /> HEALTH DEPARTNT <br /> Medical Waste Hauler Information <br /> ❑ New ® Renewal <br /> Medical Office/Business Name: FREMONT VETERINARY CLINIC <br /> Medical Office/Business Address: 2223 TP RE-W.MnNT ST- <br /> STOCKTON, <br /> City State ?ip Code <br /> Contact Person: ROBERT LINDSTROM j <br /> Phone Number: 209-465-7291 <br /> Storage Facility Name: _FRFMnNT VFTERiKARY- GI-TNTC <br /> Storage Facility Address: 2223 R. FREMONT ST_ <br /> STOCKTON, CALIF. 95PO5 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: STERICYCLE, INC. <br /> Permitted Treatment Facility Address: 2R 1 ti 1 N, KEITH DR. _ <br /> LAKE FOREST TTI- A004 <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: pARTTjp.Ej <br /> 2.Name: LARRY WATERBURY DVM Title: PARTNER <br /> 3. Name: ANN SCEARCE DVM Title: PARTNRU <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 records shall be k pt on file at generator's or health care professional's facility. <br /> /�� / . <br /> Applicant Signature: /�-a%t� � �t-�>�/-� Date: <br /> Title: PARTNER <br /> DO NO WRIT ELOW THIS LItiE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / Date Paid: /�2 h or Check#: §6-1 A Received <br /> EHE)45-02.001 <br /> 10/7/2003 <br />