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S A N �`1 A { i <br /> O Q Q I 'U ( N ° Environmental Health Department <br /> _.� C O U N T Y-- <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 /> • .� rl ," <br /> Signature : � � +,,. � &I= <br /> coo <br /> a <br /> Name and Title- tj Y, ~ e.. <br /> Date : � d b � '� <br /> 4ofII <br />