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Generator Facility Address: <br />Phone Number: <br />Generator Mailing Address: <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />1-1 <br />sltcmn U C�6ac)-I <br />City State Zip Code <br />( 9, M ) <br />City State Zip Code <br />(am ) 4-1-1 -o ?--I I <br />n Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br />-4� <br />Large Quantity Generator Only (Generates 200 lbs or more/i-nonth). <br />❑ Large Quantity Generator with Onsite Treatment (Generates 200 lbs or more/month). <br />Ir cieciare unterpeffaiti Via �,. �11 �ji <br />9tre 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 />EHD 45-03 4 <br />1(/6/2003 <br />