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REGISTRATION FOR NWICAL <br /> (Please Type or t) <br /> GENERATOR NAME: DELTA BLOOD BANK <br /> GENERATOR FACILITY ADDRESS: <br /> Street 65 North Commerce Street <br /> Stockton State CA Zip95202 <br /> City <br /> Phone Number (209 ) 943-3830 <br /> GENERATOR MAILING ADDRESS: <br /> Street P.O. Box 230 <br /> Stockton CA 95201-0230 <br /> City State Zip <br /> TYPE OF BUSINESS: Donor Blood Center <br /> AU ORIZED F SE Phyllis A. Morel, MS, NT(ASCP)SBB <br /> TI Technical Director, Compliance & Safety Officer <br /> EMERGENCY209 PHONE NUMBER: ( ) 466-9781 <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 /> OLarge Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./ o.) <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_ d the operation of this business. <br /> SIGNATURE: *44 : DATE: - l • <br /> 6 <br />