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' OCT 0 l ' <br /> UVIRONMENL.. HEALTH <br /> REGisTRAnoNFoRmEDicALwAsTE PERM IT/SERVICCES <br /> (Please Type or Print) <br /> GENERATOR <br /> GENERATOR FACI SS: <br /> Street //?--0 vs� <br /> City State Zip <br /> Phone Number ) - <br /> GENE TOR MAILING SS: <br /> Street <br /> City State Zip ��z fid' <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 /> 64 Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> OLarge 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: ° e p ®2-7 <br /> 6 <br />