Laserfiche WebLink
G'tENERATOR NAME: <br />0 0 <br />Generator Facility Address: <br />Phone Number: <br />Generator Mailing Address: <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />Ff, �.; ME RON I <br />-�—Vate Zip Cade... <br />-7, <br />lIII Quantity Generator with Onsite, Treatment (Generates less than 200 lbs/month). <br />LameQuantity Generator Only (Generates 200 lbs or more/month). <br />E] I -large Quantity Generator with OnsiteTreatment (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 />�,rxe 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: <br />Z <br />2 - <br />City X, State <br />Zip Code <br />45- <br />kle, <br />It <br />-�—Vate Zip Cade... <br />-7, <br />lIII Quantity Generator with Onsite, Treatment (Generates less than 200 lbs/month). <br />LameQuantity Generator Only (Generates 200 lbs or more/month). <br />E] I -large Quantity Generator with OnsiteTreatment (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 />�,rxe 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: <br />