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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: k- t +Z� Aq S1 S <br /> Generator Facility Address: t D ao I U <br /> L <br /> C.ty State Zip Code <br /> Phone Number: ( q) 3 3 4—cl <br /> Generator Mailing Address: 5& U (Al2 D-V& <br /> City State Zip Code <br /> Type of Business: 0 ixt r 0 ix- -S vue <br /> Authorized Representative: l e &tv-F c� + <br /> Title: ✓tt� <br /> Emergency Phone Number: <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment (Generates less than 2001bs/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: Title: Date: ?/2-7 /6 <br /> EHD 45-03 4 <br /> 2015 <br />