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0 <br /> San Joaquin County Public Health Servi <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', 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 /> 'han 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 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 S67 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 /> ❑ New 2 Renewal <br /> Medical Office/Business Name: FREMONT VETERIN <br /> Medical Office/Business Address: 2223 E. FREMONT State: r A Zp Code: a F,2 n 7 <br /> City: STOCKY Phone #r: Ona 4j6, � j <br /> Contact Person: ROBERT <br /> Storage Facility Name: <br /> Storage Facility Address: 22 2 3 E. F Stater_ ZiP Code:a r,9 n <br /> City: STOCKTON <br /> Permitted Treatment Facility Name: INTEGRATED ENVIRONMENTAL SYSTEMS <br /> Permitted Treatment Facility Address: State: A_Zip Cade: a a ti n i <br /> City: <br /> I all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> vl1RFRT T T1`rnSTROM nvM Title: <br /> RAR WRR_ <br /> 1- Name: Title: <br /> 2- Name: L TEE Title: <br /> 3_ Name: <br /> of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in <br /> A copy essiorsal's facility. <br /> addition. all copies of medical waste records shall be kept on file at generator's or health care prof <br /> Applicant Signature: <br /> Date: --�— <br /> Title: PARTNER <br /> Do Not Write Below This Line <br /> Date:�tK/'Q Expiration Date• 2 /tel (_.,�. <br /> R.E.H.S. Application Approval: <br /> EH4502 10-03-96 <br /> Date Paid /v2 / 131,000 Cash o Chec< 3a 7� (circle) Acct <br />