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SAWAA UI <br />COUNTY Environmental Health Department <br />Greatness grows here. <br />Registration for Generators of Medical Waste <br />Generator Name: Sutter Gould Medical Foundation -SMP <br />Generator Facility Address: Medical Plaza 2505 W. Hammer Lane <br />Stockton CA 95206 <br />City State Zip Code <br />Phone Number: ( 209) 550-4774 <br />Generator Mailing Address 600 Coffee Road <br />Modesto CA 95355 <br />City State Zip Code <br />Type of Business: Medical Office Building <br />Authorized Representative: Dwain Baughman <br />Title: Environmental Services Manager <br />Emergency Phone Number: (_209) 524-1211 (24 Hour Operator) <br />Registration for: <br />❑ Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br />x] Large Quantity Generator Only (Generates 200 lbs or more/month). <br />❑ Large Quantity Generator with Onsite Treatment (Generates 200 lbs or more/month). <br />I declare under penalty of law that to the best of my knowledge and belief the <br />statements made herein are correct and true. I hereby consent to all necessary <br />inspections made pursuant to the California Medical Waste Management Act and <br />incidental to the issuance of this registration and the operation of this business. <br />Signatur Title: _ Q[ Date: <br />