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REGISTRATION FOR NIEDICAL WASTE <br />(Please Type or Print) <br />L4 <br />GENERATOR NAME: O/VL). <br />City �5 /'o ck-7o-,-J State eAZ, Zip 2,1-20 Z --J <br />Phone Number G207) <br />20 <br />State (2,461t? Zip <br />ME�� <br />EMERGENCY PHONE NUMBER: ( ;Oft) 41-1— 0 <br />REGISTRATION FOR: <br />(Check One) <br />�/ 77,4 L— _ <br />Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br />(q"'- Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br />Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) <br />I declare under penalty of law that to the best of my knowledge and belief the statements <br />made herein are correct and true. I hereby consent to all necessary inspections made <br />pursuant to the California Medical Waste Management Act and incidental to the issuance <br />of this registration and the operation of this business. <br />SIGNATU TITLE: DATE: <br />6 <br />