Laserfiche WebLink
Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: +0 To 14 �yJ K <br /> Generator Facility Address: A MAP-C, cl <br /> TgrFfb <br /> City State Zip Code <br /> Phone Number: ( 2 ) 472 3 3 0 <br /> Generator Mailing Address: 1>s c5ye <br /> City State Zip Code <br /> Type of Business: 'D % +' <br /> Authorized Representative: <br /> Title: FA,, (A, <br /> Emergency Phone Number: ( 9 ) '17Z-3300 <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: /.,A .rN® XPxDate: A61,-Z17—el <br /> EHD 45-03 4 <br /> 10/6/2003 <br />