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REGISTRATION/PERMIT APPLICATION* FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATORNAME: SRI/Surgical Express <br /> GENERATOR FACILITY ADDRESS: <br /> Street 6801 Longe Street <br /> City Stockton State CA Zip 95206 <br /> Phone Number( 2 0 9) 982-5800 <br /> GENERATOR MAILING ADDRESS: <br /> Street Same <br /> City State Zip <br /> TYPE OF BUSINESS: Commercial Laundry <br /> AUTHORIZED REPRESENTATIVE: Philip Nagata <br /> TITLE: Plant Manager <br /> EMERGENCY PHONE NUMBER: (2 0 9) 9 5 2-4 2 21 <br /> REGISTRATION FOR(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.) *An <br /> Application For Medical Waste Facility Permit will be mailed to you. <br /> () 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 1 , 600 pounds <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 /> Registered Medical Waste Transporter BF I (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. I 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 /> SIGNATURE: CLk TITLE: L . DATE: <br /> (NOTE: IF YOU FILL O GISTRATION"FORM DO NOT FILL OUT"dRTIFICATION" FORM) <br /> 4 <br />