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REGISTRATION/PERMIT CATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: 1' O.i S C r r rl e -G. <br /> GENERATOR FACILITY ADDRESS: <br /> Street "7 i� <br /> City Hant'eC State Ccs, Zip—2027 <br /> Phone Number(26 ) - 5 <br /> GENERATOR MAILING ADDRESS: <br /> Street 7 G C- t <br /> City _ Carne- State f-Ot-, Zip <br /> TYPE OF BUSINESS: F- !ca I i <br /> AUTHORIZED REPRESENTATIVE: H C ►C a C-M_y <br /> TITLE: <br /> EMERGENCY PHONE NUMBER: 20 <br /> REGISTRATION FOR(Check One): <br /> () Small Quantity Generator With Onsite Treatment. (Generates <200 lbsJmo.) <br /> Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> ( ) Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) "An <br /> Application For Medical Waste Facility Permit will be mailed to you. <br /> ( ) Common Storage Facility (Small Quantity Generator using designated onsite storage area with <br /> other Small Quantity Generators for the storage of medical waste.) <br /> Please include appropriate fee when registering your facility. Fee schedule is located on Page 6. <br /> REQUIRED REGISTRATION INFORMATION: <br /> Amount (in pounds) of medical waste generated by your facility/staff per month <br /> Place an "X" next to the corresponding method your facility uses to dispose of medical waste: <br /> _Autoclave (onsite treatment) <br /> _Incineration(onsite treatment) <br /> _Microwave Technology(onsite treatment) <br /> Registered Medical Waste Transporter toriyG I E' (transporter name) <br /> _Alternative Technology Approved DHS (treatment method) <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein are <br /> correct and true. I hereby consent to all necessary inspections made pursuant to the California Medical <br /> Waste 11anagement Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> SIGNATURE: TITLE: LLDATE: <br /> (NOTE: IF FILL OU GISTRATION" FORM DO NOT FILL OUT TIFICATION" ORM) <br /> 4 <br />