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Joaquin County Public Health ices <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> i o qualify for a "Limited Quantity Hauling Exemption" pursuant to the '°Medical Waste Management A&,% the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports 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- Medicai Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> 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 to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAiL WITH $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New IS Renewal <br /> Medical Office/Business Name: FREMONT VETERINARY CLINIC <br /> Medical Office/Business Address: 2223 RG <br /> City: STOCKTON Stale: r _ Zp Code: - - <br /> Contact Person: ROBERT LINDSTROM Phone , <br /> Storage Facility Name: FREMONT VETERINARY CLINIC <br /> Storage Facility Address: 2223 E. FREMONT ST. State: CA. Zip Code: 95205 <br /> City: <br /> Permitted Treatment Facility Name: TRTTTAT, SYSTFM <br /> Permitted Treatment Facility Address: 499 HIGH STREET State: CA_.- Zip Cade: 9„4,D0 <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: ROBERT LINDSTROM DVM Title: PARTNER <br /> 2- Name: JRY DVM Title: PARTNER <br /> 3- Name: ANN SCEARCE DVM Title: PARTNER <br /> A copy of this exemption and a tracking document shall be in employee's possession at aU tunes white tim porting medical waste. in <br /> addition, all copies of medical waste records shall be kept on file at generators or health care pmfessionars facitity- <br /> Applicant Signature: <br /> Title: PARTNER Date: 12-44-0t. / <br /> Do Not Write Below This Eine <br /> Q.E.H.S. Application Approval Date:/Z! D/DI Expiration Date:ZZ /3Y /OZ <br /> EH4502 10-03-9b Date Paid (Z-/ -5 / 6 Cash or Chec< ; (circle? Acct <br />