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V �, I , 'A � 10 i <br />REGISTRA110N FORMEDICAL <br />(Please Type or <br />GENERATOR ' <br />EM <br />State 6-A S531 <br />r <br />C 0 72A 0- V State zip <br />ity —A <br />OF <br />/ ` a <br />AUTHORIZED t .. <br />►� <br />PHONEEMERGENCY <br />REGISTRATION FOR: <br />(Check One) <br />O Small Quantity Generator With Onsite Treatment. (Generates < 2001bs.f mo.) <br />Large Quantity GeneratorOnly. 0 . <br />Quantity Generator With • 0r or more lbs./mo.) <br />made herein are correct and true. I hereby cons�nt to all necessary inspections ma <br />pursuant to the California MedicalManagementAct r incidental to the issuan <br />of this registration and the operation of this business. <br />LaA&" • <br />