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On Joaquin-County Public Health Slices 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: The 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 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 $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program C(OP 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information ❑ New ® Renewal Medical Office/Business Name: FREMONT VETERINARY CLINIC Medical Office/Business Address: 2223 E. FREMONT ST P.O. BOX 1952 City- STOCKTON State: CA Zip Code:95201 Contact Person: ROBERT LINDSTROM Phone #: 209-465-7291 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: CA Zip Code: 94601 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: PARTNFR 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-fecords shall-be kept on file at generator's or health care professional's facility. Applicant Signature: Title: PARTNER Date: 3 / :_24 8 Do Not Write Below This Line R.E.H.S. Application Approval �z__ Date: rr/ z /��Expiration Date: /Z /,5 T EH4502 10-03-96 Date Paid t ! / �c /9 / Cash or Check # is 51:5� (circle) Acct ! .