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00 <br /> REGISTRATION/PERMIT APPLICATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: <br /> GENERATOR FACILITY ADDRESS: - <br /> Street <br /> City _ State Zip <br /> Phone Number <br /> GENERATOR MAILING ADDRESS: <br /> Street <br /> City State Zip <br /> TYPE OF BUSINESS: <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: <br /> EMERGENCY PHONE NUMBER: j ) <br /> REGISTRATION FOR(Check One): <br /> () Small Quantity Generator With Onsite Treatment. (Generates <2001bsJmo.) <br /> O Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> O 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 <br /> Place an "X" next to the corresponding method your facility uses to dispose of medical waste: <br /> Autoclave (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. I hereby consent to all necessary inspections made pursuant to the California Medical <br /> Waste Management Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> SIGNATURE: TITLE: DATE: <br /> (NOTE: IF YOU FILL OUT"REGISTRATION"FORM DO NOT FILL OUT"CERTIFICATION' FORM) <br /> 4 <br />