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S A N d 0 A Q U ' N Environmental Health Department I <br /> -----C O U N T Y <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 /> 1LSignature: tr_— L%,, a-'-��;= <br /> 0 <br /> Name and Title, <br /> Date: t h <br /> 4of11 <br />