Laserfiche WebLink
® for Medical Waste <br /> For Generators of Medical to <br /> -jO-- <br /> GENERATORN <br /> AME: <br /> Generator Facility Address: 1 :53 Y Sm jjn� 1�am Zavi -e- <br /> LOC4 fLly ;?- <br /> City $tate Zip Code <br /> 39 <br /> Phone Number 6 2- <br /> Generator Maiting Address: <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: <br /> Title: <br /> Emergency Phone Number: a o I <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 site 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 /> 41 Signature: Title: ��Ie: 41 <br /> EHD 45-03 4 <br /> 10612003 <br />