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Registration r Medical Waste <br /> For Generators of Medical Waste <br /> i <br /> GENERATOR NAME: Q, <br /> I <br /> Generator Facility Address: + <br /> ,t State Zip Code <br /> Phone Number: (29) `�f 5 b�b <br /> Generator Mailing Address: —D G <br /> C-41-V <br /> C,� �52Es"I <br /> City State Zip Code <br /> Type of Business: Lyn rA 0 Yl b <br /> Authorized Representative: <br /> Title: <br /> Emergency Phone Number: (_ ) UDC1 m CACa�il� <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> iKarge 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: 1 1177 j� <br /> EHD 45-03 4 <br /> 10/6/2003 <br />