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S A N 1 O A Q U I N Environmental Health Department <br /> -COUNTY-- - <br /> Registration for Generators of [Wedical Wa to <br /> Generator Name: <br /> Generator Facility Address: -�235r 8 C-a-� :�ocn iC. S�-co-o-+ <br /> City State Zip Code <br /> Phone Number: a lqq <br /> Generator Mailing Address: �- <br /> City State Zip Code: <br /> Type of Business: -S LA.c'�tL�--, <br /> Authorized Representative: : <br /> Title: c '2! <br /> Emergency Phone Number:D-0°h I LI(4 9 l aU <br /> Registration for: <br /> ❑ Small Quantity Generator with Onsite Treatment (Generates less than 200 Ibs/month), <br /> Large Quantity Generator Only (Generates 200 Ibs or more/month). <br /> ❑ Large Quantity Generator with Onsite Treatment (Generates 200 lbs or more/month). <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 <br /> of this business. <br /> Signature: f — Title: 1����r� S k" vA Date:3 zy�z <br /> 5of11 <br />