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Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: <br />Generator Facility Address: <br />Phone Number: <br />Generator Mailing Address: <br />Type of Business: <br />Authorized Representative <br />Title: <br />Emergency Phone Number: <br />REGISTRATION FOR: <br />California Health Care Facility <br />7707 S. Austin Rd <br />Stockton CA 95213 <br />City State Zip Code <br />( ) 209-467-4673 <br />P.O. Box 32050 <br />Stockton CA 95215 <br />City State Zip Code <br />Correctional Treatment Facility <br />Stephanie Peterson <br />Correctional Health Services Administrator II <br />(209 ) 993-7909 <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 />❑✓ Large Quantity Generator with Onsite Treatment (Generates 200 lbs or more/month). <br />I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br />are correct and true. I hereby consent to all necessary inspections made pursuant to the California <br />Medical Waste Management Act and incidental to the issuance of this registration and the operation <br />of this business. <br />Signature: <br />EHD 45-03 4 <br />10/6/2003 <br />7 <br />