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REGIS TRATION/PERNI(IT APPLICATION* FORNIEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: 1,ntegrated Patholoqy Services Corporation <br /> GENERATOR FACILITY ADDRESS: <br /> Street 2291 West March Lane #179E <br /> City —Stockton State CA Zip 95207 <br /> Phone Number(M) 477-4432 <br /> GENERATOR MAILING ADDRESS: <br /> Street Same as Above <br /> City State Zip <br /> TYPE OFBUSINESS: Clinical Patholoqy Laboratory <br /> AUTHORIZED REPRESENTATIVE: David R Dani J)L4 br2i b- <br /> TITLE: Safety / Environmental Compliance Manager <br /> EMERGENCY PHONE NUMBER: ( 209 477-4432 <br /> REGISTRATION FOR(Check One): <br /> Small Quantity Generator With Onsite,_Treatment. (Generates <200 lbsJmo.) <br /> Large Quantity Generator Only. (Generates 200 or more lbsJmo.) <br /> Large Quantity Generator With Onsite Treatmem (Generates 200 or more tbs./mo.) *An <br /> Application For Afedical Waste Facility Per will be mailed to you. <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 400 <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 /> _Nficrowave,Technology (onsite treatment) Systems <br /> _X_Registered Medical Waste Transporter Integrated Environmental �L(tt-ansporter name) <br /> —Alternative Technology Approved DHS (treatment method) <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein are <br /> correct and true. I hereby consent to all necessary inspections made pursuant to the California Vfedical <br /> Waste 11anagement Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> a <br /> Safety and Environmental Compliance <br /> SIGNATURE: David R�Dani 1 =E: Manager DATE: Aug 8, 2000 <br /> (NOTE: IF YOU FILL OUT"REGISTRATION"FORM 00 NOT FILL OUT"CERTIFICATION" FORM) <br /> 4 <br />