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SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Registration for Generators of Medical Waste <br /> Generator Name: DaVita Grant Line Dialysis <br /> Generator Facility Address: 2955 N. Corral Hollow Road, Suite 101 <br /> Tracy CA 95376 <br /> City State Zip Code <br /> Phone Number: ( 209 ) 839-8302 <br /> Generator Mailing Address: Tracy CA 95376 <br /> City State Zip Code <br /> Type of Business: Outpatient Dialysis Center <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 /> V 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 <br /> made herein are correct and true. I hereby consent to all necessary inspections made <br /> pursuant to the California Medical Waste Management Act and incidental to the issuance of <br /> this registration and the operation of this business. <br /> Signature: Title: Facility Administrator Date:2/2/2021 <br />