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E GISTRATION FOR MEDICAL <br /> (Please Type or Print) <br /> GENERATOR E: <br /> GENERATOR FACILITY ADDRESS: <br /> Street <br /> City State Zip, <br /> Phone N ber ( ) <br /> GENERATOR MAILING ADDRESS: <br /> Street <br /> City State Zip <br /> TYPE OF BUSINESS: <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: <br /> EMERGENCY PHONE NUMBER: ) <br /> REGISTRATION FOR: <br /> (Check one) <br /> O Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> OLarge 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 DATE: <br />