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A � . <br /> REGISTRATION I WASTE <br /> (Please Type or Print) <br /> 1'-u Tv ATl1R M *(E: Kaiser Permanente <br /> GENERATOR FACE=ADDRESS: <br /> Street 530 West Acacia <br /> r <br /> City Stockton State Calif Zip 95210-3364 <br /> Phone Number (209 ) 476-2000 <br /> GENERATOR MAIUNG ADDRESS: <br /> Street. 1395 Tommydon_ Street <br /> City Stockton State CA Zip 95210-3364 <br /> TYPE OF.BUSINESS: Healthcare Kaintenance organisation <br /> AUTHO REPRFS A John C. Farrell <br /> T TITLE: Medical office Administrator <br /> EMERGENCY-PHONE" . `( 2 09 , 476-3300- <br /> . . <br /> REG ATION'FOR: <br /> (Check Mlle) <br /> t S tity Generator Yfith..Onsite Tzea==L- (Genetates < 200 lbs/mo:) <br /> Quantity.'Generator Only. (Generates 200 or more lbs./mo.) <br /> ( j Large Quantity Generator With °te .(Generates 2(O or more lbs./mo.) <br /> I declare under penalty of law that to the best of my 1powled <br /> ge and belief the.statements <br /> made herein are correct and..true. I lit-to all necessary ` etions made . <br /> pursuant to the California Medical wafte Mapaginnent Act_and.incidental to-the issuance <br /> of this registration-and the operation of dis • ss. <br /> DATE• <br /> SIGNATURE: . <br /> I <br /> 6 <br />