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Y 0 <br /> E GISTRATION FOR AMICAL_ <br /> (Please Type or t) <br /> GENERATOR E: a5AN JOAQUIN ARTIFICIAL KIDNEY CENTER . TNC. <br /> GENERATOR FACIIM ADDRESS: <br /> Street 415 E. HARDING WAY, SUITE F <br /> City STOCKTON State CA. Zip 95204 <br /> Phone (209 ) 465-7655 <br /> GENERATOR MAILING ADDRESS: <br /> Street SAME AS ABOVE <br /> City State Zip <br /> TYPE OF BUSINESS: HEMODIALYSIS CENTER <br /> AUTHORIZED REPRESENTATIVE: GEORGE HERRON <br /> TITLE: PRESIDENT <br /> EMERGENCY PHONE NUMBER: (2 0 9 ) 4 6 5-7 6 5 5 <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 /> ( ) 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 this business. <br /> SIGNATURE: DATE: <br /> 6 <br />