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l <br /> ' 6 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATORNAME: <br /> Generator Facility Address: <br /> Tm <br /> City State Zip Code <br /> Phone Number: ® ) LA a6 <br /> Generator Mailing Address: <br /> City State Zip Code <br /> 6 <br /> Type of Business: ' <br /> mcifm <br /> Authorized Representative: ! <br /> 1-0 <br /> Title: 1-1 LA <br /> cg-k <br /> Emergency Phone Number: <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> JK 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 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 <br /> of this business. <br /> Signature: Title: wnmtpgqit <br /> EHD 45-02-003 Page 4 of 7 <br /> i if l'MAz <br />