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, e <br /> 0 <br /> Registration a is Ste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: '} cA <br /> Generator Facility Address: 1 f a t' 4 . <br /> QMec CCI. <br /> city State Zip Code <br /> Phone Number: ) &3 - 302E <br /> Generator Mailing Address: 5. mcw*-, � <br /> City State Zip Code <br /> Type of Business: i o.1®/ C '` ;c— <br /> Authorized Representative: f`�` y P Y- <br /> Title: C-CV\ I, 0 1'(ecr <br /> Emergency Phone Number: <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 tot the issuance of this registration and the operation <br /> of this business. <br /> a <br /> Signature: Title•cey1 el- t fft Date: 6-/0-0s <br /> EHD 45-02-003 Page 4 of 7 <br /> inIfIrMl <br />