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SANJOAQUIN <br />—COUNTY— <br />Environmental `} <br />viron ental Health Department <br />Greotness grows here. <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT <br />REQUIRED TO REGISTER <br />Business Name: Sutter Gould Medical Foundation <br />Business Address: Stockton Medical Plaza 2505 West Hammer Lane <br />Stockton Calif 95209 <br />City State Zip Code <br />Phone Number: (_209) 521-6097 Ext. 2306 <br />Contact Person: Dwain Baughman Environmental Services Manager <br />I am not required to register as a Medical Waste Generator because: <br />Please check the appropriate statement(s) <br />❑ 1 do not generate any medical waste. <br />❑ 1 generate less than 200 pounds of medical waste per month. <br />❑I do not treat any medical waste at my facility by means of autoclaving, incinerating or <br />X microwaving. <br />❑ Other <br />Please indicate the appropriate statement(s): <br />❑ I declare under penalty of law that to the best of my knowledge and belief, I do not generate or <br />store any of the wastes specified on the "Pre -Application Questionnaire" as regulated medical wastes <br />in an amount that equals or exceeds 200 pounds per month. <br />n I declare under pens of law that 1 will not be treating any amount of regulated medical wastes at <br />my acility by way of a to 15. g, incinerating or microwaving. <br />Signature Title: u,00_ rV 1 Date: 3 25 19 <br />