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s <br /> 10/30!97 THU 12:15 FAX 707 00331 RAY CHERNISKE 2004 <br /> .L.t (a) <br /> REGISTRATION/PERMIT/ APPLICATION <br /> FOR <br /> MEDICAL WASTE GENERATION AND TREATMENT <br /> As of January 1991, all.generators of regulated medical waste are subject to <br /> the registration requirements pursuant to the Medical Waste Management Act. <br /> To register your facility, complete and send this application along with a <br /> medical waste managementplan (if applicable) , and the permit fee (see fee <br /> schedule) to: Department of Health Services, Medical Waste Management <br /> Program, P. O. Box 942732, MS# 396, Sacramento, CA 94234-7320. <br /> Note: This application will not be processed until all required <br /> information has been received and fee(s) have been submitted. <br /> LOCATION OF Gr'2JE ATOR: (Please Print or Type) <br /> Business Name: M i l; ka i I�,edi ca 1 C Ad tet- - [a fz) . <br /> Business Address: qLi . Ee-},J /�uP <br /> city: _ I State: CA <br /> zip: +S 37& county: &J %-a c L ;,J <br /> Authorized Reuresentative: <br /> Title: C�"`- <br /> �urse c e x4p Phone Number: { ) X33 5. <br /> TYPE OF GENERATOR: (Check one) <br /> ( ) small Quantity Generator - If your facility generates less than 200 lbs <br /> of medical waste a month. <br /> { ) Small ouan-itv Generator with Onsite Treatment —If your facility <br /> generates less than 200 lbs a month and treats the medical waste onsite <br /> by autoclaving, incinerating or microwaving. <br /> (X) Large Ouanzity Generator - If your facility generates 200 lbs or more <br /> of medical waste a .month and hires an authorized registered hazardous <br /> waste hauler to pick up the medical waste for proper disposal. <br /> ( ) Large Quantity Generator with Onsite Treatment <br /> if you; facility generates 200 lbs or more a month and treats the <br /> medical waste onsite . by autoclaving, incinerating or microwaving. <br /> { ) Common Storaae Facility Permit <br /> Any designated accumulation area which is Onsite and is used by small <br /> quantity generators otherwise operating independently for the storage of <br /> medical waste for collection by a registered hazardous waste hauler. <br /> If you are registering as a medical waste generator, please continue to fill <br /> out the reverse side of this form. If you do not generate regulated medical <br /> waste, please complete pre-applicatioa questionnaire for declaration of non <br /> medical waste generators,` <br />