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SARJOAQUINEnvironmental Health Department <br />COUNTY <br />Registration for Generators of Medical Waste <br />Generator Name: <br />Generator Facility Address: <br />iv <br />;vt <br />c V- 4". , CA� <br />City State Zip Code <br />Phone Number: 19 1 ) T7 7 — D Z"] 1 <br />Generator Mailing Address: S cc ^�-- <br />City State Zip Code: <br />Type of Business: <br />Authorized Representative: : <br />Title: <br />Emergency Phone Number:() 7tr <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 made <br />herein are correct and true. I hereby consent to all necessary inspections made pursuant to the <br />California Medical Waste Management Act and incidental to the issuance of this registration and the <br />operation of this business. <br />Signature: 140m� Title: Date: <br />5of11 <br />