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i • <br /> Medical Waste Generation and Treatment <br /> Application for Registration <br /> Generator Facility Alpha Therapeutic Corporation <br /> Site Address 429 E.March Lane#F <br /> City Stockton State CA Zip %w r <br /> Mailing Address 5555 Valley Blvd. <br /> City Los Angeles State CA Zip 90032 <br /> Telephone (209)477-8632 <br /> 9 <br /> Authorized Representative AMA179 <br /> AVIV,1 <br /> Title Center Director <br /> Emergency Telephone (323)227-7225 <br /> This facility is currently a: <br /> ❑ Small quantity generator ❑ On-site treatment ❑ Common storage facility <br /> ® Large quantity generator ❑ Large quantity generator/on-site treatment <br /> Type of facility (Large quantity generator).- <br /> E] <br /> enerator):❑ Hospital-#beds ❑ Skilled Nursing Facility-#beds ❑ Laboratory <br /> ❑ Psychiatric Hospital ❑ Clinic-Specify: ® Blood Bank <br /> Note: We are a plasma donor center;we have checked"blood bank"as the closest category available. <br /> Please include appropriate fees and a copy of the facility's Medical Waste Management Plan. <br /> "I declare under penalty of the law that to the best of my knowledge and belief, the statements made herein are correct and <br /> true. I hereby consent to all necessary inspections made pursuant to the California Medical Waste Management Act and <br /> incidental to the issuance of this permit and the operation of this business." <br /> Name: o erto Chavez Title: Environmental, Health& Safety Engineer <br /> Signature: Date: g <br />