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02/19/1995 03:10 20946574ag FREMONT VET CLI PAGE 02 <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Prcgram <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption!' pursuant to the"Medical Waste Management Acf, 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 an die one of the following: <br /> Medical 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 INFORMAnoN SELqW AND MAIL WM Se-r F-r_F_ 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 /> C3 New 0 Renewal <br /> Medical office/Business Name. FREMONT V.ETEEINILS1 Cir-TVIC <br /> Medical Office/Business Addrass: 2223 E. FREMONT.-..ST. R.O.StBOX 3 !a!i1 <br /> State: a r <br /> City: r2T!2g.jSjQbj Zip Code:. ,)nj <br /> Contact Person*-ROPART LINDSTROM Phone <br /> Storage Facility Name, EIRE jQNM_YjaEJR IN <br /> Storage Facility Address: 2223 IT <br /> City: STOCKTON Stgte:_CA�_Zlp Code:9 5 20,5 <br /> permitted Treatment Facility Name: INTEGRATED ENVIRONME.N. STEM&_, <br /> .......... <br /> Permitted Treatment Facility Address; state: __CA�Zp Code: 0AAn1_ <br /> CltT- nAK AXTT).. <br /> OWN <br /> I upw <br /> List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. <br /> Name: ROBEE1 LIND.SMU Ely Title: DA321rikilon __ __ <br /> 2- Name: <br /> Title: <br /> By HATE Tiller' <br /> e: <br /> 3- Name: <br /> A copy of this exemption and a tracking doewnent shad be in 8mPl*Y**'V 130456smic"at a"dmes while transporting medical W860. in <br /> addition, all copies of medical waste recarft shad be kept an file at gamratM1,3 or health cw*prolassiamrs faculty. <br /> Applicant Signature* <br /> Title: PARTNER _-Datet 3 2 / 3 3 On <br /> Do Not Write 3elow This Line <br /> oate:j;��Expiratlon DatejZ <br /> U.H.S. Application Approval: T- t 9.0 1 1 . <br /> EH4502 10-03-96 Date Paid /�_j-00Cash o(_C_h;&)P_j32Z.2_(circle) Acte P_ <br />