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46 6 <br /> REGISTRATION FOR MEDICAL WASTE <br /> 1. GENERATOR NAME: ST. DOMINIC'S HOSPTIAL <br /> 2. GENERATOR FACILTY ADDRESS: 1777 WEST YOSEMITE AVE MANTECA CA. <br /> 3. PHONE NUMBER: 209-825-3545 <br /> 4. MAILING ADDRESS: 1777 WEST YOSEMITE AVE MANTECA CA. 95337 <br /> 5. TYPE OF BUSINESS: HOSPITAL <br /> 6. AUTHORIZED REPRESENTATIVE: MARCEL L. SMITH <br /> 7. TITLE: SUPPORT SERVICES MANAGE <br /> 8. EMERGENCY PNONE NUMBER(S): 209-825-3545 (Office) or 209-983-7601 (PGR) <br /> 9. REGISTRATION FOR: <br /> • ❑ Small Quantity Generator With Onsite Treatment. (Generates<200 lbs. /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. <br /> I DECLARE UNDER PENALTY OF LAW THAT THE BEST OF MY KNOWLEDGE <br /> AND BELIEF THE STATEMENTS HERIN ARE CORRECT AND TRUE. 1 HEREBY <br /> CONSENT TO ALL NECESSARY INSPECTIONS MADE PURSUANT TO THE <br /> CALIFORNIA MEDICAL WASTE MANAGEMENT ACT AND INCIDENTAL TO THE <br /> ISSUANCE OF THIS REGISTRATION AND THE OPERATION OF THIS BUSINESS. <br /> SIGNATURE: Marcel L. Smith Title: Support Services Manager Date: 6/19/02 <br /> PRE-APPLICATION QUESTIONAIRE <br /> Please check the appropriate response for the questions listed below. <br />