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T 0 <br /> REGISTRATION FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: Delta Health Care <br /> GENERATOR FACILITY ADDRESS: <br /> Street 911 Industrial.Way <br /> City Lodi State CA Zip 95240 <br /> Phone Number ( 209) 369-2704 <br /> GENERATOR MAILING ADDRESS: <br /> Street 914 North Center Street <br /> City Stockton State CA Zip 95202 <br /> TYPE OF BUSINESS: Community Clinic <br /> AUTHORIZED REPRESENTATIVE: Irwin D. Staller, M.P.H. <br /> TITLE: Executive Director <br /> EMERGENCY PHONE NUMBER: ( 20 ,66,-3245 <br /> REGISTRATION FOR: <br /> (Check One) <br /> ( Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> O Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> ( ) Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) <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 <br /> of this registration and the operation of this business. <br /> Executive <br /> SIGNATURE. t - : Director DATE: <br />