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SA NUJ U 1'1 Q U IN , 'Environmental Health Department <br /> COUNTY <br /> Medical Waste Facility Registration <br /> Facility Name: 0-.Y3'�t1 �1 � �C� �� ' <br /> Facility Address: V` � <br /> City, State, Zip Code: °�rz C A� Ch - <br /> Mailing Address: 6 & J6 <br /> City, State, Zip Code: <br /> Phone Number: <br /> Facility Contact and Title: ae �,, � b' � �' `C-ElC� <br /> Facility Registration Category: <br /> ❑ Small Quantity Generator(<200 pounds per month)with Onsite Treatment. <br /> X Large Quantity Generator(>=200 pounds per month)with Onsite Treatment. <br /> ❑ Large Quantity Generator(>=200 pounds per month)without Onsite Treatment. <br /> ❑ Common Storage Facility (2-10 generators) <br /> ❑ Common Storage Facility(11-50 generators) <br /> ❑ Common Storage Facility(> 50 generators) <br /> 3ofII <br />