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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: Vr <br /> Generator Facility Address: 9) SS; u ir►n, -Law <br /> City State Zip Code <br /> Phone Number: � ).��g"-�l�C <br /> Generator Mailing Address: ['[ �� t� lw( 1 d,4.J2 <br /> 4-1 C/1-- l rzz �- <br /> Ciity/ State Zip Code <br /> Type of Business: <br /> r <br /> Authorized Representative: L ` <br /> Title: �i� <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 /> ❑ 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: SLGDate: <br /> EHD 45-03 4 <br /> 10/6/2003 <br />