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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: Manteca Dialysis <br /> Generator Facility Address: 1620 W Yosemite Ave <br /> Manteca CA 95337-5190 <br /> City - State Zip Code <br /> Phone Number: 209 925-3905 <br /> Generator Mailing Address: 5200 Virginia Way, L&C Dept <br /> Brentwood TN 37027 <br /> City State Zip Code <br /> Type of Business: Dialysis Facility <br /> Authorized Representative. James Hilger <br /> Title: Chief Accounting Offier <br /> Emergency Phone Number: ( 209 ) 825-3905 <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> ❑E 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: Title: C �1� - kCc qhA Date: `1-8- K-0 <br /> EHD 45-03 4 <br /> 10/6/2003 <br />