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SA N J O A Q U IN Environmental Health Department <br /> COUNTY— <br /> Medical Waste Facility Registration <br /> Facility Name: <br /> Facility Address: <br /> City, State, Zip Code: `� (UG l—f��/� G� �d <br /> Mailing Address: �� V14 'wd\ - b"A I <br /> City, State, Zip Code: J j 'I UG `�^ e-- A <br /> C) -7 <br /> Phone Number: �Ll G� 6 <br /> Facility Contact and Title: )C_so�_ cc ! ' <br /> Facility Registration Category: <br /> ❑ Small Quantity Generator (<200 pounds per month) with Onsite Treatment. <br /> ❑ Large Quantity Generator (>=200 pounds per month) with Onsite Treatment. <br /> E Large Quantity Generator (>=200 pounds per month) without Onsite Treatment. <br /> ❑ Common Storage Facility (2-10 generators) <br /> ❑ Common Storage Facility (11-50 generators) <br /> ❑ Common Storage Facility (> 50 generators) <br />