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W �I <br /> . REGISTRATION/PERIVIIT APPLICATION FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: ��, +3���. �. �t cy ���.'�"il ��- L„ hC "c\1 tC''►_L. <br /> GENERATOR-FACILITY ADDRESS: <br /> Street A] cu _i , Lout- <br /> city <br /> orpt-City State Cl\ 7'p <br /> Phone Numbers <br /> GENERATOR iV1AILING ADDRESS: <br /> Street OM(,j <br /> City L j,� li State C p j t` ?_ <br /> TYPE OF BUSINESS: YIQ�),t -i(• lkut.iGurN <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: C(' %'►1 <br /> EMERGENCY PHONE NUMBER: (3,)')) ,),.)....1 - JJJ'i <br /> REGISTRATION FOR (Check One): <br /> O Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> Lane Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> ( ) Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) "An <br /> Application For Medical Waste Facility Permit will be mailed to yon. . <br /> O Common Storage Facility (Small Quantity Generator using designated onsite storage area with <br /> other Small Quantity Generators for the storage of medical waste.) <br /> Please include appropriate fee when registering your facility. Fee schedule is located on Page 6. <br /> REQUIRED REGISTRATION INFORMATION: <br /> Amount (in pounds) of medical waste generated by your facility/staff per month –7 5 C' <br /> Place an "X" next to the corresponding method your facility uses to dispose of medical waste: <br /> _Autoclave (onsite treatment) <br /> —Incineration (onsite treatment) <br /> _Microwave Technology (onsite treatment) <br /> X.Registered Medical Waste Transporter_6V 1 Nh"a Ict..t,,_-c�i l i`;ry,(transporter name) <br /> _Alternative Technology Approved DHS (treatment method) <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein are <br /> correct and true. 1 hereby consent to all necessary inspections made pursuant to the California Medical <br /> Waste Management Act and incidental to the issuance of this registration and the operation of this <br /> business. <br /> SIGMATU li. TITLE: <br /> (NOTE: IF YOU FILL OUT <br /> 1 "REG�TRATION" FORM DO NOT FILL OUT"CERTIFICATION" FORNI) <br /> 4 <br />