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GENERATOR NAME: <br />REGISTRATION FOR MEDICAL WASTE <br />(Please Type or Print) <br />Lodi Memorial West <br />GENERATOR FACILITY ADDRESS: <br />Street <br />City _ <br />800 South Lower Sacramento Road <br />Lodi <br />Phone Number ( 209 1333 4311 <br />GENERATOR MAILING ADDRESS: <br />Street <br />City <br />State CA Zip <br />800 South Lower Sacramento Road <br />Lodi <br />95240 <br />State CA Zip 95240 <br />TYPE OF BUSINESS: General Acute Care Hospital <br />AUTHORIZED REPRESENTATIVE: Richard Sandford <br />TITLE: Administrator <br />EMERGENCY PHONE NUMBER: ( 209 ) 334 3411 Ext 7560 <br />REGISTRATION FOR: <br />(Check One) <br />() Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br />�j Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br />() Large Quantity Generator With Onsite Treatment. (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 herein 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 business. <br />L I <br />SIGNATURE: -2 r TITLE: Admi ni stratorDATE: ,f/H h 2-- <br />2 <br />2 <br />