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LES 'ON AVS101 6lR -lZ 'unr <br /> Environmental Health Department <br /> SAWOAQUIN <br /> 0 U N TY..---- <br /> Registration for Generators of Medical Waste <br /> Generator Name: <br /> Generator Facility Address: <br /> City State Zip Code <br /> Phone Number: 016ci LA-I <br /> Generator Mailing Address: <br /> City State Zip Code <br /> Type of Business: SY-AeA N(L-n <br /> Authorized Representative: AA+kz." <br /> Title: <br /> Emergency Phone Number: 4-1-1 �AO-I] <br /> Registration for: <br /> El Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br /> large Quantity Generator Only (Generates 2D0 lbs or.more/month). <br /> Lj 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 <br /> made herein are correct and true. I hereby consent to all necessary inspections made <br /> pursuant to the California Medical Waste Management Act and incidental to the issuance of <br /> this registration and t peration of this business. <br /> Signature. Title: AVMI ST F-A"Ib 4- Date:2LI 3LI <br /> 4 of 8 <br />