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May, 13. 2011 9:OOAM <br />(GENERATOR NAME: <br />S.n Joaquin County <br />LI <br />Registration for Medical Waste <br />For Generators of Medical Waste <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 />No, 1896 P. 5/9 <br />City state zip Code <br />f ® ) %i >---1 <br />City State Zip Code <br />T ®w't 40 21A� <br />I <br />❑ mall 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 Is 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 />EHL? 45-03 <br />