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Regiistrationfor Medical Waste RECEIVED <br /> ForGenerators of Medical Waste APR 18 2011 <br /> GENKRATORNA.ME: De� 4* /�"6 t- <br /> Gene rator Facility Address: 133 Y Sey Nwl <br /> lxc�4 C4 <br /> C'ty <br /> Phone Stft Zip Code <br /> Numbw. R-61 3 4 - 39 2, <br /> Generator Mailing Address: <br /> city staft Zip Code <br /> Type of Business: C, <br /> Authorized Representative: rCZ YN,i"d <br /> Title: <br /> Emergency Phone Number: ( 2 j ) <br /> REGISTRATION FOR: <br /> Small Quantity Generator with Onsite Treatment(Generates less than 200 ib nth). <br /> Large Quantity Generator Only(Generwes 200 lbs or more/month). <br /> El Large Quantity Generator with Onsite Treatment(Generates 200 lbs,or morelmonth). <br /> I deckm 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: RLIIAA4a�- Date: <br /> EM 45-03 4 <br /> tO/&2003 <br />