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SAR)JOAQUIN Environmental Health Department <br /> COUNTY— <br /> Registration for Generators of Medical Waste <br /> Generator Name: PTIA QuAll, WK-e- <br /> Generator Facility Address: -{Zose, � avie- Ll� <br /> C* <br /> City State Zip Code <br /> Phone Number: ( ),C?01) -1 66Z-I <br /> Generator Mailing Address: <br /> City State Zip Cade: <br /> Type of Business: 1" uqsau!�� <br /> J <br /> Authorized Representative: <br /> Title: <br /> Emergency Phone Number:( <br /> Registration for: <br /> R Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br /> �g Large Quantity Generator Only (Generates 200 lbs 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 <br /> herein are correct and true. I hereby consent to all necessary inspections made pursuant to the <br /> California Medical Waste Management Act and incidental to the issuance of this registration and the <br /> operation of this business. <br /> S ig nature:G11j,',la 1,12e� Title: Date:11aZ& <br /> 5 of 11 <br />