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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: RM-West March-Brookside vormed3a Gambro Healthcare-San joaq In) <br /> Generator Facility Address: 3115 West March Lane <br /> Stockton CA 95219 <br /> City State Zip Code <br /> Phone Number: f 209 ) 955-7527 <br /> Generator Mailing Address: Same as above <br /> City State Zip Code <br /> Type of Business: End Stage Renal Disease(ESRD) outpatient fallity <br /> Authorized Representative: <br /> Title: Center Director <br /> Emergency Phone Number: -7 2 6-- q -2 6 <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br /> Large Quantity Generator Only (Generates 200 lbs or more/month). <br /> ❑ Large Quantity Generator with Onsite Treatment (Generates 200 lbs or more/month). <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are correct and true.I hereby consent to all necessary inspections made pursuant to the California <br /> Medical Waste Management Act and incidental to the issuance of this registration and the operation <br /> of this business. <br /> Signature: 4d 0::::j ljg�l� Title: Center Direder Date: of <br /> EHD 45-02-003 Page 4 of 7 <br /> .Tn&llnAl <br />