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RE GISTRA71ON FORrWR-mi <br />(Please Type or Print) <br />GENERATOR NAME: Deuel Vocational Instution <br />Street 23500 Kasson Road <br />City Tracy <br />State CA Zip 95378-0400 <br />Phone Number( 209 ) 835-4141 , extension 4440 <br />Street <br />P.O. Box 400 <br />City Tracy State C A Zip <br />TYPE OF BUSINESS• State Prison <br />AUTHORIZED REPRESENTATIVE: Gilbert R.- S a i n z. M. D. <br />TITLE: Health Care Manager <br />95378-0400 <br />EMERGENCY PHONE NUMBER: ( 2 0 9) 835-4141, extension 4440 <br />REGISTRATION FOR: <br />(Check One) <br />() Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br />(X) 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 Medicalaste Management Act and incidental to the issuance <br />er of this regis tion and the open on o business. <br />SIGNATURE• Gilbert R. Sainz .D. TITLE: HCM DATE: <br />2 <br />