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Registration Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: <br />Generator Facility Address: <br />Phone Number: <br />Generator Mailing Address: <br />Lbwtae <br />..r <br />City State Zip Code <br />s 01) qeL "gg55, <br />City State Zip Code <br />�^ <br />Type of Business: L &Lt&r K aK Ciarz %,.c�'►�O�S <br />Authorized Representative: 1,err ac "rh <br />Title: cpnt A Idq e/' <br />Emergency Phone Number: ( 201) Z- q 55, <br />❑ Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br />' Large Quantity Generator Only (Generates 200 Ibs 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: <br />I <br />W- <br />mo-C414,Date: <br />0 IVA <br />EHD 45-03 4 <br />10/6/2003 <br />F "'6 " 202- <br />