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RE-GISM'flON FOR WMICAL WASTE <br />El I <br />(Please 7Wel or Print) <br />OCT 2 4 <br />'01-1 <br />GENERATOR NAME: LINCOLN FAMILY MEDICAL GROUP INC. EN0,o°iENTAL HEALTH <br />I 7SERVICE-5 <br />GENERATOR FACILrI`Y ADDRESS: <br />Street 800 DOUGLAS ROAM /2509 W. MARCH LN.,/2415 W. VINE ST.( LODI <br />City STOCKTON LODI State CA Zip qq2n7 4a52A <br />Phone Number( 209 ) 957-7050 <br />Street 800 DOUGLAS ROAD <br />City STOCKTON State -... CA Zip 95207 <br />TYPE OF BUSINESS: MEDICAL GROUP <br />AUTHORIZED REPRESENTATIVE: SHEILA M. FREUERICKSEN <br />CENTRAL SUPPLY , NURSING DEPT. <br />EMERGENCY PHONE NUMBER: ( 209 ) 474-0781 ( MARC SMITH, DMINISTRATQLJ_ <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 />N. <br />