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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: �y eP, C9 E L AtZc��" <br /> Generator Facility Address: : R. ) -r <br /> KT , I CID <br /> City State Zip Code <br /> Phone Number: (T ) <br /> Generator Mailing Address: <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: <br /> Title: ry 1ST T <br /> Emergency Phone Number: ( ) 3-3 X i <br /> DL— <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 Onsite Treatment(Generates 200 lbs or more/inonth). <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: - - Title 74 Dalt&3( -rC( ate: <br /> EHD 45-03 4 <br /> 10/6/2003 <br />