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P Z�To(7- <br /> REGISTRATION/PE T APPLICATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: 0 es+ -DiaC1 Y1DS4iL CLtr,1' <br /> C0_1 W D rq-fDru <br /> GENERATOR FACILITY ADDRESS: <br /> Street 2291 W Mand) Larne #1L5F <br /> city 5+oC.Kt0n State CA Zip 9,cia07 <br /> Phone Number 2LOih 9 5I -5Tj3 I <br /> GENERATOR MAILING ADDRESS: ' <br /> Street 5 arYLP. <br /> City State Zip <br /> TYPE OF BUSINESS: t t..Gl ar -fur <br /> AUTHORIZED REPRESENTATIVE: 'J) <br /> TITLE: Are—&- NlA-y'l Q Q ems' <br /> EMERGENCY PHONE NUMBER: (2-Oq) 95[- 5S'31 l ae�sar� <br /> REGISTRATION FOR(Check One): <br /> ( ) Small Quantity Generator With Onsite Treatment. (Generates <200 lbsJmo.) <br /> (v)' 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 tlledical Waste Facility Permit 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 <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) fi `, c(C <br /> ✓Registered Medical Waste Transporter porter 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 :Idedical <br /> Waste iWanagement Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> SIGNATURE: ]y TITLE: ry1Sb r DATE: -711q100 <br /> (NOTE: IF YOU FILL OUT"REGISTRATION'FORM DO NOT FILL OUT"CERTIFICATION" FORM) <br /> 4 <br />