Laserfiche WebLink
REGISTRATION FOR MEDICAL WASTE <br />(Please Type or Print) <br />GENERATORNAME: Lt, t&5 -r [GanVI-tIL <br />City ni-e- C t State 2L Zip <br />Phone Number L A a <br />GENERATOR MAILING ADDRESS: <br />` MI Wt� <br />city State _ Zip <br />TYPE OF BUSINESS: "-il R&ItbA&IN-a� <br />AUTHORIZED REPRESENTATIVE: UwroL R. Bedo <br />0 11 <br />RMERGENCY PHONE NUMBER: ( @0j <br />REGISTRATION FOR: <br />(Check One) <br />Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br />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 />SIGNATURE: V11hi- P1 T=:gAj OS/) DATE: j2-ZY--J?, <br />VV <br />6 <br />