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MAY-03-11 09:22 FROM- T-093 P-0T/13 F-402 <br /> Registration a ical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: f/<' ee ) 6t�g, <br /> Generator Facility Address: ; !`"' m,4A <br /> 4 <br /> Ciry State Zip Code <br /> Rhone Number- <br /> Generator Mailing Address: <br /> 37 <br /> Ciry Stale Zip Code <br /> Type of Business: 5A,1/1 a4, -1 O �� �� •, • <br /> Authorized Representative: <br /> Title: i<?e c o <br /> Emergency Phone Number: GS a 6- <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month)_ <br /> i.-�Lge 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 sary 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 /> r <br /> Signature: - Title: <br /> Date:''`` l <br /> EM 45-03 <br /> 1016/2003 <br />