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S oaquin County Public Health Serlos Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the following conditions must be met The generator or health care professional generates less than 20 pounds of medical waste per weak, 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 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 WITH S67 FEF TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information Q Newer Renewal Medical Office/Business Name: FREMONT VETERINARY CLINIC Medical Office/Business Address: 2223 E . FREMONT ST. STOCKTON Contact Person: State:�A. .Zip Code: 9520 City. BERT LINDSTROM Phone - Storage Facility Name:FREMONT VETERINARY CLINI Storage Facility Address: 2 2 2 3 E. FREMONT ST. State: CA. Zlp Coder n r City: STOCKTON Permitted Treatment Facility Name: STERICYCLE INC. Permitted Treatment Facility Address: 28161 N. KEITH DR. State. _IL• Zip Cade: 60045 City: LAKE FOREST List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. TRnM DVM Title: PARTNER Name:ROBERT LINDS Title: PARTNER 2- Name:LARRY WATERBURY DVM Title: RARTMVP - 3_ Name:ANN SCE RCE DVM on and a tracking document shalt be in employee's possession at all times while transporting medical waste. in a copy of this exempts essionar's facility. addition. all copies of medical waste reco shall be kept on file at generator's or health care prof tY- Applicant Signature: Date: 1 1 '--�/ Title: PARTNER Do Not Write Below This Line oval• R.E.H.S. Application Appr Dater Expiration Date: l /V EH4502 10-03-96 Date Paid j� l L4 l ® L Cash or Check 4._ Acct (circle) .