Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> COUNTY— i <br /> Registration for Generators of Medical Waste <br /> Generator Name: LAgf ( A lC rUJ� <br /> Generator Facility Address:_. <br /> b�° amen <br /> City State Zip Code <br /> Phone Number: (20 ) <br /> Generator Mailing Address: �2m C.mgZ <br /> City State Zip Code: ,(��� <br /> Type of Business: �(; L1X �� <br /> Authorized Representative: :�� ��,���\V� ?1t _ d')kry-�Cxk-)n <br /> Title: <br /> Emergency Phone Number:(ZD% ) 6p0 6 - --7 3 % 3 <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 inspectlons made pursuant to the California <br /> Medical Waste Managemen Act and incidental to the issuance of this registration and the operation <br /> of this business. <br /> Signature: Title ( �t'�o� Date: <br /> 5 of 11 <br />