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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENE RXfOR NAME: k-Vt ht L,,-Dtt4 <br /> Generator Facility Address., 1610 W, t(Oue-VOW JAVU.1, �O <br /> Lbdj ...... .... PA q 157,0� 2. <br /> Lf—"I J) state Zip Code <br /> Phone Number: 33 <br /> Generator Mailing Addrms: <br /> city Sia1c lip Code <br /> I <br /> Type of Business: (V-Kkoc"4915 C-tt.VLJC, <br /> Authorized Representative: <br /> Title: <br /> Emergency Phone Number: <br /> REGISTRATTONFOR: <br /> F-1 Small Quantity Generator with OnsitcTreaftnent(Ohmeratt!sless than 200 lbs/nionfli). <br /> Large Quaptity Generatoi Only(Generates2001bs ormoro/manth), <br /> ❑ Large Quantity Glenerator with.Onsite Treatment(Generates 200 lbs of morehnonffi). <br /> T 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: ?&7Z-2V1-6 <br /> H D 45-0:3 4 <br /> 2015 <br /> [ 'd 9H8 'IN Ndfl :� 9106U ,d;S <br />