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REGISTRATION/PERMIT APPLICATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: A IN ep I Ch/U kt ehcW Aa.0o&i e-, <br /> GENERATOR FACILITY ADDRESS: <br /> Street �� E L""VW s4z "s <br /> City 5-10 6 A 4'y f State (4,2- Zipg�-?0 <br /> Phone Number('fiK) q Y14 o 7 <br /> GENERATOR MAILING ADDRESS <br /> T <br /> Street 5 ?5 S , Rv&cl <br /> Sou 74 r vA <br /> City r Pr At re State r4- <br /> TYPE OF BUSINESS: V L'feve4t f)4"V <br /> (21 <br /> AUTHORIZED REPRESENTATIVE: D'oty ' �2d4vli6t <br /> TITLE: ./APP Afbv 1-_140 ell- 34 Pe 4 1 Re'sk 1O y/' <br /> EMERGENCY PHONE NUMBER: 317- & k1 A4 je r <br /> REGISTRATION FOR(Check One): <br /> Small Quantity Generator With Onsite Treatment. (Generates <200 lbsJmo.) <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 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-1,50-a 0 0 4 <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 �Iff;C L/C le., _(transporter name) <br /> —Alternative Technology Approved DHS I (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 :Ilfedical <br /> Waste -:111ana-ement Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> OR! <br /> 66�YOUFILLUT(6REG ISf R)�JqdN'° FORM DO NOT FILL OUT C ICATIONV.;� <br /> SIGNATURE —TITLE: .� 12. �k r DATE: 2— <br /> (NOTE: IF YOU F1 <br /> 4 <br />