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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: <br /> Generator Facility Address: '7110--Al <br /> /I/ — <br /> City State Zip Code <br /> Phone Number: -q) <br /> Generator Mailing Address: 7 Y C2 /V, <br /> .940C-k:101V 4� <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: <br /> Title: <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 /> El Large Quantity Generator with Onsite Treatment(Generates 200 lbs or more/month). <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are 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 /> Signature: Title: 45X76zL DOF—' Date: <br /> HID 45-03 4 <br /> I 1 1,2-1 <br /> 016003 <br />