Laserfiche WebLink
Jan. 24. 2019 11 : 34AM SUTTER TRACY HOSPITAL No. 8271 P. 3/6 <br /> 1 <br /> SAN 10AQUIN <br /> Environmental Health Department � <br /> COUNTY <br /> i <br /> Registration for Generators of Medical Waste <br /> �' fro. Va1)J-Ll kosp 4a I , d ►o j <br /> Generator Name: r r �� S , 2 <br /> i <br /> Generator Facility Address: ,�2 e) hA %Q,. c j ,)1 <br /> , <br /> City State Zip Code <br /> Phone Number: L)9 ) <br /> Generator Mailing Address: G -7 G <br /> City State Zip Code <br /> i <br /> Type of Business: v A C <br /> i <br /> Authorized Representative: �- <br /> j <br /> Title: Z-V $ ffiAeel A C, r <br /> I <br /> Emergency Phone Number: (d o• ► u� <br /> I <br /> Registration for: <br /> i <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> \Large Quantity Generator Only (Generates 200 lbs or more/month), <br /> I <br /> ❑ Large Quantity Generator with Onsite Treatment(Generates 200 lbs or more/month). <br /> 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 of <br /> this regis r Ion and the operation of this business. <br /> Signature: Title: — ., Date: —lq <br /> �®re <br />