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Sa aquin County Public Health Servicas 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 Act', the following conditions must be met: T he generator or health care professional generates less than 20 pounds of medical waste per week, 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 Man 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 FEE 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 ❑ New IN Renewal Medical Office/Business Name: FREMONT VETERINARY CLINIC Medical Office/Business Address: 2 2 2 3 E. FREMONT ST. P.O. BOX 1952 City: STOCKTON State: CA _ Zip Code: 95201 Contact Person: ROBERT LINDSTROM Phone ;:2ng_465_7991 Storage Facility Name: FREMONT VETERINARY CLINIC Storage Facility Address: 2223 E. FREMONT ST. City: STOCKTON State: CA Zip Code.95205 Permitted Treatment Facility Name: INTEGRATED ENVIRONMENTAL SYSTEMS Permitted Treatment Facility Address: 499 HIGH STREET City: OAKLAND State: r_A _Zip Cade:9 6 n i List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: ROBERT LINDSTROM. DVM Title: PARTNER 2- Name: LARRY WATERBURY, DVM Title: PARTNER 3- Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition, all copies of medical waste records shad be kept on file at generators or health care professional's facility. Applicant Signature: 7 Title: , , �� Date: 3 3 -14 99( -- 77 Do Not Write Below This Line R.E.H.S. Application Approval: A41., Dater 1 /D Expiration Date: Z/31 /2OoO EH4902 10-03-96 Date Paid Cash or Check T d9OL2 (circle) Acct (Z2---