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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: rwuwwj <br /> Generator Facility Address: vOn e <br /> City State Zip Code <br /> Phone Number: a? ) Y-73-3mV <br /> Generator Mailing Address: 41e- A,S 446CAJIf- <br /> city State Zip Code <br /> Type of Business: 'I 41r9ir% ocd,& <br /> Authorized Representative: 1, <br /> Title: i/IeST r <br /> Emergency Phone Number: <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/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: Title: Date: 9 <br /> EHD 45-03 4 <br /> 2015 <br />