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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: l�N IV�RS� jljle� DhGlF-lG <br /> Generator Facility Address: 751 242ooK-SlDE pt.). <br /> -EgVC,r-Tof-1 God. 95211 <br /> City State Zip Code <br /> Phone Number: ( w9 ) lq(,, 1Co`{S <br /> Generator Mailing Address: 3W I Pki n C, Ai <br /> -i"[10C.it' ?o <br /> City State Zip Code <br /> Type of Business: �1V�TE UNIVW=gilI:Y <br /> Authorized Representative: C1SNE <br /> Title: M&&:&2MQVr Tr- h7 &uf4 <br /> Emergency Phone Number: <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: Z Title: Date: $T7011 <br /> 1CAA-j <br /> E14D 45-03 4 <br /> 10/6/2003 <br />