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ix <br /> Registration a icaWaste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: Pvj Pos -r �y� <br /> Generator Facility Address: �_���7 <br /> City State Zip Code <br /> Phone Number: 67-6q <br /> Generator Mailing Address: <br /> City State O Zip Code <br /> Type of Business: L f.of t\30rj( C 2 <br /> Authorized Representative: LA-Q /\4- ^ <br /> Title: C�'A tye 0l-(,eZ 06-(2, <br /> Emergency Phone Number: `� -vqr q 5e <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 taw 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 issuance of this registration and the operation <br /> of this business. <br /> Signature: Title: l� �'0�' Dater if - <br /> EHD 45-03 4 <br /> anFr�nra `" <br />