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1-1 <br />Si Iffl � <br />ao= <br />Environmental Health Department <br />Generator Name: Omnicare of Northern California #48214 <br />Generator Facility Address: 850 S. Guild Ave. <br />Lodi CA 95240 <br />City State Zip Code <br />Phone Number: ( 209 ) 333-4900 <br />Generator Mailing Address: One CVS Drive (Mail Code 2340), Woonsocket, RI 02895 <br />City State Zip Code <br />Type of Business: Long-term care pharmacy <br />Authorized Representative: Nicole Wilkinson <br />Title: Director, Corporate Environmental <br />Emergency Phone Number: ( 888 ) 464-2960 <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 <br />made herein are correct and true. I hereby consent to all necessary inspections made <br />pursuant to the California Medical Waste Management Act and incidental to the issuance of <br />this registrati and the o eration of this business. <br />Signature: Title: Director, Corporate Environmental Date: <br />4of8 <br />