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SA N J O A Q U I N Environmental lealth Department <br /> - —COUNTY <br /> Registration for Generators of Medical Waste <br /> Generator Name: Grant Line Dialysis <br /> Generator Facility Address: 2955 N CORRAL HOLLOW RD STE 101 <br /> Tracy CA 95375-880 <br /> City State Zip Code <br /> Phone Number: ( 209 ) 839-8302 <br /> Generator Mailing Address: 5200 Virginia Way L&C Dept <br /> City State Zip Code: Brentwood, TN 37027 <br /> Type of Business: Kidney Dialysis <br /> Authorized Representative: : Courtney vela <br /> Title: Facility Administrator <br /> Emergency Phone Number:( ) 682-239-7879 <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 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 regist-ation and the operation <br /> of this business. <br /> Courtney Vela p iea20signed <br /> 21013094L42y 7e00' Facility Administrator 10-13-2022 <br /> Signature: Title: Date: <br /> 5of11 <br />