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REGISTRATIONIPERMIT APPLICATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATORNAME: AI Qh. nTln�, <br /> GENERATOR-FACILITY ADDRESS: <br /> Street 14 D-9 E. C rt^ in La ne # F <br /> City `5i pcy,_tBu State _C&_ 7ip C�5 a 0-7 <br /> Phone Number (—DR) a <br /> GENERATOR MAILING ADDRES <br /> Street 555 5) Vg1lev Ivd. <br /> City La,, le L State GA Zip 9I(nA;; <br /> ,5 wl) yo 1,v ��,0 <br /> TYPE OF BUSINESS: I <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: e r 140: <br /> EMERGENCY PHONE NUMBER: �)) 5QL 5RZ6_V, -MZ <br /> REGISTRATION FOR (Check One): <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.) *An <br /> Application For iWedical Waste Facility Permit will be mailed to yor.. ; <br /> ( ) Common Storage Facility (Small Quantity Generator using designated onsite storage area with <br /> other Small Quantity Generators for the storage of medical waste.) <br /> Please include appropriate fee when registering your facility. Fee schedule is located on Page 6. <br /> REQUIRED REGISTRATION INFORMATION: <br /> Amount (in pounds) of medical waste generated by your facility/staff per month `75 Q <br /> Place an "X" next to the corresponding method your facility uses to dispose of medical waste: <br /> _Autoclave (onsite treatment) <br /> !Incineration (onsite treatment) <br /> _Microwave Technology (onsite treatment) <br /> X Registered Medical Waste Transporter BF-,L Wicnj Wotij e sv5+eAjs(transporter name) <br /> _Alternative Technology Approved DHS (treatment method) <br /> 1 declare under penalty of law that to the best of my knowledge and belief the statements made herein are <br /> correct and true. 1 hereby consent to all necessary inspections made pursuant to the California illfedical <br /> Waste 111anagement Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> 1 eq -- <br /> SIGNATU TITLE: _�`�'„-z DATE., q 66 '— <br /> t(NOT IF "REG RATION" FORM DO NOT FILL OUT"CERTIFICATION" FORM) <br /> oI:0 <br />