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eglstration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERA.TORNAME: 'RaJtJ✓w�Ac�icJ� �kalcp.�t CGV1� <br /> Generator Facility Address: Sia® Cav-r iA14 vi Cif. <br /> sk-06�0v% CA S-A10 <br /> City State Zip Code <br /> Phone Number: (a -1 y7 3.. 5,004 <br /> Generator Mailing Address: $ww t <br /> City State Zip Code <br /> Type of Business: 5kalkc� Il�Hvsi ng ira ci te'}1► <br /> Authorized Representative: SOVI <br /> Title: AAW►eyW,O5. r,Aoy" <br /> Emergency Phone Number: ( a0i `l7 3-3604 <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> [f 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 /> c <br /> Signature: Title: w ioll 64r Date: 71S <br /> EHD 45-03 4 <br /> 10/6/2003 <br />