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S A N�`1 A{ i <br /> O Q Q I'U (N ° Environmental Health Department <br /> ---COUNTY-- <br /> Large Quantity Generator (LQG) Facility Category(defined in HSC 117995): <br /> ❑ Acute Care Hospital <br /> ❑ Primary Care Clinic <br /> ❑ Skilled Nursing Facility <br /> ❑ Veterinary Clinic <br /> Other LQG <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 /> • <br /> Signature: � �,�._+,,. �_ &t= <br /> i� <br /> a <br /> Name and Title r � � ►� ~ `, ti <br /> Date: <br /> 4ofII <br />