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SA N J O A Q U I N Environmental Health Department <br /> ---- - _, �i T�1",' <br /> Large Quantity Generator (LOG) Facility Category (defined in HSC _§ 117995): <br /> ❑ Acute Care Hospital <br /> ❑ Primary Care Clinic <br /> ❑ Skilled Nursing Facility <br /> ❑ Veterinary Clinic <br /> L' Other LOG <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are correct and true. I hereby consent to all necessary inspections made pursuant to the California <br /> Medical Waste Management Act and incidental to the issuance of this registration and the operation of <br /> this business. <br /> i , <br /> Signature.- <br /> Name and Title: J ctC >>c�_ -� <br /> Date: I �c� <br />