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Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: �� ILDI III JAS A <br />Generator Facility Address: blo l�f f t& <br />it 5 <br />Ci1w State Zip Code <br />Phone Number: ( ) -- <br />Generator Mailing Address: Job 9 11")v <br />o <br />City State Zip Code <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />( ark ) %�-1569 <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: <br />EHD 45-03 4 <br />1 Alfnnnz <br />