Laserfiche WebLink
REGISTRATION/PERMIT APPLICATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: m ll l i K-,J i ca-L (PA Ar f_- E4403 <br /> GENERATOR FACILITY ADDRESS: <br /> Street Li Li s w. Ea.L2 ) u e-- <br /> City -Tt-A e.t4 State Zip 39,d <br /> Phone Number(a&A a 3 3 - 5 3 3 5 <br /> GENERATOR MAILING ADDRESS: <br /> Street <br /> City State Zip <br /> TYPE OF BUSINESS: L+; Se ec_> <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: 0 V r se H A_j 04 le <br /> EMERGENCY PHONE NUMBER: ) Q e-J <br /> REGISTRATION FOR(Check One): <br /> () Small Quantity Generator With Onsite Treatment. (Generates <2001bs./mo.) <br /> Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> () Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) *An <br /> Application For Medical Waste Facility Permit will be mailed to you. <br /> () Common Storage Facility (Small Quantity Generator using designated onsite storage area with <br /> other Small Quantity Generators for the storage of medical waste.) <br /> Please include appropriate fee when registering your facility. Fee schedule is located on Page 6. <br /> REQUIRED REGISTRATION INFORMATION: <br /> Amount(in pounds) of medical waste generated by your facility/staff per month 60 Lb s . <br /> Place an "X" next to the corresponding method your facility uses to dispose of medical waste: <br /> _Autoclave (onsite treatment) <br /> _Incineration(onsite treatment) <br /> Microwave Technology (onsite treatment) - <br /> _kRegistered Medical Waste Transporter` v ,2f transporter name) <br /> _Alternative Technology Approved DHS (treatment method) <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein are <br /> correct and true. I hereby consent to all necessary inspections made pursuant to the California Medical <br /> Waste Management Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> SIGNATURE: TITLE: t ATE: <br /> (NOTE:` IF YOU FILL OUT"REGISTRATION"FORM DO NOT FILL OUT"CERTIFICATION"FORM) <br /> 4 <br />