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REGISTRATION FOR MEDICAL WASTE <br />(Please Type or Print) <br />GENERATORNAME: Lodi Memorial Hospital East <br />GENERATOR FACILI'T'Y ADDRESS: <br />Street 975 S. Fairmont Avenure P.O. Box 3006 <br />City <br />Lodi <br />Phone Number 1209 ) 334 3411 <br />GENERATOR MAILING ADDRESS: <br />State CA Zip <br />Street 975 S. Fairmont Aventue P.O. Box 3006 <br />City <br />Lodi <br />TYPE OF BUSINESS: General Acute Hospital <br />State CA Zip <br />AUTHORIZED REPRESENTATIVE: Richard Sandford <br />TITLE: Administrator <br />EMERGENCY PHONE NUMBER: ( 209) 334 3411 Ext 7560 <br />REGISTRATION FOR: <br />(Check One) <br />_95240-5118 <br />95240-5118 <br />() Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br />() Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br />(x) 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. I hereby consent to all necessary inspections made <br />pursuant to the California Medical Waste Management Act and incidental to the issuance <br />of this registration and the operation of this business. <br />SIGNATURE: <br />`F TITLE: AdministratorD7y,TE; <br />P <br />