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Registration Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: 30a(I'twoa4G316& <br /> Generator Facility Address: pf��Imc,, X151 lYc�' <br /> q52—7 <br /> 5 <br /> State Zip Code <br /> Phone Number: <br /> Generator Mailing Address: t>151 N Q-- i (if 6")Y 0 <br /> kAw\ (A 51 <br /> City State Zip Code <br /> Type of Business: U1fi <br /> Authorized Representative: U l <br /> 5 <br /> Title: I- v t&yc� <br /> Emergency Phone Number: (20 <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 to the issuance of this registration and the operation <br /> of this business. <br /> %Signature• Title: b 11 <br /> EHD 45-03 4 <br /> 10/6/2003 <br />