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S A N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Large Quantity Generator (LQG) Facility Category (defined in HSC 117995)• <br /> ❑ Acute Care Hospital <br /> ❑ Primary Care Clinic <br /> ❑ Skilled Nursing Facility <br /> ❑ Veterinary Clinic <br /> Other LQG <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are correct and true. I hereby consent to all necessary inspections made pursuant to the California <br /> Medical Waste Management Act and incidental to the issuance of this registration and the operation of <br /> this business. <br /> Signature: <br /> Name and Title: T-CQ L1" M QEZL �W '( — Ungl�MCK/r I J <br /> Date: /Dq I <br /> 4of11 <br />