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SA N J O A Q U I N Environmental Health Department <br /> --COUNTY— <br /> Registration for Generators of Medical Waste <br /> , <br /> Generator Name: S ( <br /> �I �� Alt �( �tlG�Ct�,IC)� Anl <br /> �a <br /> Generator Facility Address:_ � �• `�(a�jne�� , <br /> City State Zip Code <br /> Phone Number: (2cq ) <br /> Generator Mailing Address: (VM�; <br /> City State Zip Code: <br /> Type of Business: <br /> Authorized Representative: : <br /> Title: cif✓ ` )11 n'�CV1��[�1� <br /> Emergency Phone Number:(20'/ <br /> Registration for: <br /> ❑ Small Quantity Generator with Onsite Treatment (Generates less than 200 Ibs/month). <br /> Large Quantity Generator Only (Generates 200 Ibs or more/month). <br /> ❑ Large Quantity Generator with Onsite Treatment (Generates 200 Ibs 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 Managemen Act and incidental to the issuance of this registration and the operation <br /> of this business. <br /> Signature: Title• l��[ of ate. <br /> p : <br /> U <br /> 5 of 11 <br />