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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: r-CL C V 1 <br /> Generator Facility Address: �>— ky Place <br /> c , <br /> City IState Zip Code <br /> Phone Number: <br /> Generator Mailing Address: <br /> City State Zip Code <br /> Type of Business: e o t 1 S 1 n% <br /> Authorized Representative: Car 6Ls+,(!! 1 o R-p <br /> Title: Ch r Di i— <br /> Emergency Phone Number: ( a 0q ) 1 <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 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: 4t4ZWn Title: Cep lei Cf C Date: <br /> EHD 45-02-003 Page 4 of 7 <br /> t A/C MMR <br />