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SA N O Q Q V 111 Environmental Health Department <br /> --COUNTY— <br /> Medical Waste Facility Registration <br /> Facility Name; �I� '�. �{ rj} i i t�C f• � � ' <br /> Facility Address: r� �� {�. l._ 1► l1 N Yl,�l� � - ►�� <br /> City, State, Zip Code: <br /> Mailing Address: S-bme- C 0-6ye <br /> City, State, Zip Code: <br /> Phone Number: ��i " 1o� r.. ALO '?�Lo <br /> le ,Facility Contact and Title: , i � <br /> Facility Registration Category: <br /> ❑ Small Quantity Generator(<200 pounds per month) with Onsite Treatment. <br /> 1 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 /> 3 of 11 <br />