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REGISTRATION FOR MEDICAL <br /> (Please Type or t) <br /> GENERATOR NAME: <br /> GENERATOR FACILrIY ADDRESS: <br /> Street ' <br /> City State Zip <br /> Phone Nu mber <br /> GENERATOR MAILING ADDRESS: <br /> Street <br /> City State Zip <br /> TYPE OF BUSINESS: , <br /> r. <br /> AUTHORIZED SE A : <br /> `f <br /> TI ° <br /> EMERGENCY PHONE BER: ) <br /> REGISTRATION FOR: <br /> (Check One) ' <br /> ( ) Small Quantity< Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> OLarge Qu tity Generator Only. (Generates 200 or more lbs./mo.) <br /> OLarge Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo-) <br /> I declare er penalty of law that to the best of my knowledge and belief the statements <br /> made here* are correct and true. I hereby consent to all necessary inspections made <br /> pursuant o the California Medical Waste Management Act d incidental to the issuance <br /> of this r °stration and the operation of this business. <br /> SIGNATURE: DATE: <br /> 6 <br />