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APR-06-11 10:34 FROM- 0 0 T-853 P.07/13 F-873 <br /> Registration Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: <br /> Generator Facility Address: � <br /> ll�u i�i �a.�AA3 <br /> Ci State Zip Code <br /> Phone Number: ( 91 <br /> Generator Mailing Address: <br /> efA <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: <br /> Title: �A e e roe <br /> Emergency phone Number: <br /> REGISTRATION FOR: <br /> V <br /> all Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> ge Quantity Generator Only(Generates 200 lbs or more/month). <br /> [] Large Quantity Generator witliOnsite 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 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 /> Title: 0�� Date <br /> EHA 45-03 a <br /> 10/612003 <br />