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Registration r Medical Waste <br /> For Generators of Medical Waste <br /> , <br /> GENERATOR NAME: ,- r1 Y1 Gt 1 �- • <br /> Generator Facility Address: 1 to z 0 0 712P, 1 .11. -' <br /> q7z <br /> City State Zip Code <br /> Phone Number: ( Z J2— <br /> Generator Mailing Address: ' <br /> City , State Zip Code <br /> Type of Business: <br /> Authorized Representative: j 1 AZL <br /> Title: 1 tr,t /f—f_ t r (3/t/ <br /> � ® <br /> Emergency Phone Number: <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> 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 lav that to the best of my knowledge and belief the statements made herein <br /> are correct anci 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 /> i <br /> Signature: Title: U Date: <br /> EHD 45-03 4 <br /> 10/6/2003 <br />