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Registration for Medical Waste <br /> For (:enerators of Medical Waste <br /> GENERATOR NAME:: 1.02, �,5,��_"W,"� e <br /> Generator Facility Address: <br /> City Statc Zip Code <br /> Phone Number: <br /> Generator Mailing Address: X 4 M t= <br /> City State �! Zip Code <br /> Type of Business: <br /> Authorized Representative: JAG���F�' ,///!G G % _ <br /> Title: oq t. �IwM/,.57.*rflp off- <br /> Emcrbcney Phone Number: 02�) <br /> REGISTRATION FOR,: <br /> Small Quantity Generator with nntiite'Treatment(Generates less than 200 lbs/month). <br /> barge Quantity Generator Only (Generates 200 lbs or more/month). <br /> (] Large Quantity Generator with Onsite Treatment(Generates 200 lbs or more/month). <br /> 1 declare under penalty of law that to the bent of my knowledge and belief the statements shade herein <br /> are correct and true. 1 hereby consent to all necessary inspections made pursuant to the California <br /> Medical Wuste Management Act tint) incidental to the issuance of this registration and the operation <br /> of this business. <br /> Signature: _._.._.—TitIe: T.W�rli' Date; <br /> EI ID 45-03 4 <br /> 1 OW2003 <br /> 9T/£'d 2612889t,:01 :WOdJ TT:ZT TTOZ-£T-AdW <br />