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fz- <br />SEP 3 0 1991 <br />REGISTRATION FOR MEDICAL WASTEE N V 1 R 0 W11 (--'N17[Ai-, HEALTH <br />(Please Type or Print) P E R M IT/ "S E' R V ICES <br />Street 521 S. Ham Lane, Suite F <br />City Lodi State -..- CA Zip 95242 <br />Phone Number ( 2 0 9 ) 333-0905 <br />Street Same as above- - <br />City State - Zip <br />TYPE OF BUSINESS: Pmbulatory Sur5ical Center <br />§UTHORIZED REPRESENTATIVE: marklin E. Brown <br />TITLE: Administrator <br />EMERGENCY PHONE NUMBER; ( 209) 368-6543 Or 333-2098 <br />REGISTRATION FOR: <br />(Check One) <br />Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br />Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br />Jt Large Quantity Generator With Onsite Treat ment. (Generates 200 or more lbs./mo.) <br />I declare under penalty of law that to the best of my knowledge and belief the statements <br />made herem' are correct and true. I hereby consent to all necessary inspections made <br />pursuant to the California Medical Waste Management Act and incidental to the issuance <br />of this registration and the operation of this business. I <br />SIGNATURE:'94;1a,/x9- TITLE: af�wAma DATE: <br />N. <br />