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m <br />REGISTRATION FOR MEDICAL WASTE <br />(Please Type or Print) <br />!_OATMR AT_ R MKaiser Permanente <br />GENERATOR FACILITY ADDRESS: <br />Street 7373 West Lane <br />City <br />Stockton <br />Phone Number ( 209 ) 476-2000 <br />GENERATOR MAILING ADDRESS: <br />Street 1305'Tommydon Street <br />State Calif Zip 95210-3364 <br />City Stockton State CA Zip 95210-3364 <br />TYPE OF BUSINESS: Healthcare Maintenance organization <br />AUTHORIZED REPRESENTATIVE John C. Farrell <br />. .Medical .Office Administrator <br />EMERGENCY PRONE NUMBER:- ( z 0 9 1.. 476-3360: <br />REGISTRATION -FOR: <br />(Check One) <br />O .Small- Quantity Generator With Onsite Treatment. (Generates < 200 lbs,/mo.) <br />O Large Quantity Generator Only. (Generates .200 or more. lbs./mo.) <br />0. Large Quantity Generator With -Onsite Treatment. (Generates 200 or more lbs./mo.) <br />I declare under penalty -of law that. to the best of my knowledge and belief the statements <br />made herein- are correct and. true: 1. : hereby co0sent. to: all necessary inspections. made <br />Pursuant to the California Medical Wste Management Act and. incidental to the issuance <br />of this registration and the operation -of this business. <br />SIGNATURE: TMLE: DATE: iz, r <br />R <br />