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San quin-County Public Health Servic� 4tnvironmental 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 ProgramQ 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information ❑ New ® Renewal Medical Office/Business Name: FREMONT VETERINARY CLINIC MedicalOffice/Business Address: 2223 E. FREMONT ST. P.O. BOX 1952 City: STOCKTON State: CA. Zip Code:95201 Contact Person: ROBERT LINDSTROM, DVM Phone * 209-465-7291 Storage Facility Name: FREMONT VETERTNARY CLINIC Storage Facility Address: 2223 E FREMONT ST. City: STOCKTON State:C- Zip Code: 95205 Permitted Treatment Facility Name: TmT-PrPAT-Rn RNVTRomm-FNTAT. c;YgTE.MG Permitted Treatment Facility Address:dqa gTr r�cmRERT City: n n XT ANT) State:CA Zip Code: o a F n 1 List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: RnRF.RT T.TmnsTRnm. T)VM 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 white transporting medical waste. In addition, all copies of medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: J% ✓� �l��d/� Title: PARTATRR Date: 12 - /t R r / A-7 Do Not Write Below This Line R.E.H.S. Application Approval: Date: 12/2Z/ piration Date:_ Z! 3 / EH4502 10.03-96 Date Paid G-/9� Cash or hec # (circle) Acct V91 , CL)