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REGISTRATION/PERMIT APPLICATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATORNAME: h&-M 116,c71/ C gE - 5 er ,4z START('t-c to <br /> GENERATOR FACILITY ADDRESS: <br /> Street ./6?/ 6,j) / ,-,00tTs6 6AI9 <br /> City S kro aJ) State C4 Zip Zi o <br /> Phone Number LL ) 962 - () 6� <br /> GENERATOR MAILING ADDRESS: <br /> Street P ®. /6Cy <br /> City S TOC State CA Zip 9Sa0 <br /> TYPE OF BUSINESS: 1I/6� SC#eo.�- CAImPus <br /> AUTHO ZED REPRESENTATIVE: 6t97 (E0&,uz10 `UP <br /> TITLE: _ 12/A_e70R or- Q_A1A) '(?4e_ �' d>C F'S <br /> EMERGENCY PHONE NUMBER: 06 9 ) P 71 - X r <br /> REGISTRATION FOR(Check One): <br /> (VT, Small Quantity Generator With Onsite Treatment. (Generates <200 lbs./mo.) <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 Medical 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 - ? f / . <br /> Place an "X" next to the corresponding method your facility uses to dispose of medical waste: <br /> VAutoclave (onsite treatment) <br /> —Incineration(onsite treatment) <br /> Microwave Technology (onsite treatment) <br /> Registered Medical Waste Transporter (transporter name) <br /> —Alternative Technology Approved DHS (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. 1 hereby consent to all necessary inspections made pursuant to the California Jdedical <br /> Waste Management Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> SIGNATURE: ZKL4 A TITLE: `DATE: - % i 9 <br /> (NOTE: IF YOU FILL OUT"REGISTRATION" FORM DO NOT FILL UT"CERTIFICATION" FORM) <br /> 4 <br />