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California Drug Take-Back Program
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1.
Contact Information (1 application per facility)
(Required.)
Facility Name
Name of Person completing form
Facility Address
Telephone
Email
Hours of operation for facility
DEA registration license number (not applicable to Law Enforcement)
If you’re a pharmacy or hospital, or you are partnering with a authorized collector pharmacy, provide the
Board of Pharmacy facility license number
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2.
Will the bin be accessible to the public?
(Required.)
Yes
No
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3.
Which of the following best describes where the medicine collection receptacle will be located (pick one):
(Required.)
Pharmacy
Hospital/clinic with on-site pharmacy
Law enforcement
Skilled nursing facility
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