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REGIS TION FOR UEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: EDISON HEALTH CENTER <br /> GENERATOR FACILITY ADDRESS: <br /> Street 1425 South Center <br /> City Stockton State ,CA_ Zip as7nti <br /> Phone Number(20.9 ) 547-3990 <br /> GENERATOR MAILING ADDRESS: <br /> Street P.O. Box 550 <br /> City Stockton State CA. Zip i_nssn <br /> TYPE OF$USINESS: Medical Clinic <br /> AUTHORIZED REPRESENTATIVE: Sara Godwin, N.P. <br /> TITLE: Director of Clinical Garvirac <br /> EMERGENCY PHONE NUMBER: ( 209 ) 466-3245 <br /> REGISTRATION FOR: <br /> (Check One) <br /> M 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.) <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 Medical Waste Management Act and incidental to the issuance <br /> of this registration and the operation of this business. - <br /> SIGNATURE: : A <br /> 6 <br /> 6 <br />