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_rI"I 14URdIx <br />Registration for Medical Waste <br />For Generators of Medical Waste <br />Generator Facility Address: u r -u <br />ILAl <br />City State Zip Code <br />Phone Number: ) <br />Generator Mailing Address:ye- <br />city State Zip Code <br />Type of Business: - a ; f <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />❑ Small Quantity Generator with Onsite Treatment (Generates less than 2001bs/month). <br />ZI 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 <br />EHD 45-03 4 <br />10/6/2003 <br />