Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> -C O U N TY----- <br /> Registration fo <br /> Y----- <br /> ist ti r Generators of Medical Waste <br /> Generator Name- Xwl- \/ <br /> Generator Facility Address: I <br /> City State Zip Code <br /> Phone Number: ( �f- <br /> Generator Mailing Address: �-- <br /> City State Zip Code: <br /> Type of Business: <br /> Authorized Representative: A16Af ! L <br /> Title: PlAgc703 0 /L/ Z% <br /> Emergency Phone Number: l <br /> Registration for: <br /> ,x Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br /> ie,-Large <br /> 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 statements made <br /> herein are correct and true. I hereby consent to all necessary inspections made pursuant to the <br /> California Medical Waste Management Act and incidental to the issuance of this registration and the <br /> operation of this business. <br /> Signatur Title: A DaterkAl <br /> 5 of 11 <br />