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0 0 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: Li <br /> Generator Facility Address: <br /> Phone Number: Citystale jigs Code <br /> Generator Mailing Address: <br /> City <br /> State Zip Code <br /> J'ype of Business: <br /> Authorized Representative: <br /> Title: <br /> -�A <br /> Emergency Phone Number: <br /> REGISTRATION FOR: <br /> P- S"nall Quantity Generator with onsite Treatment(Generates less than 200 lbs/month). <br /> 19 l:,argeQuaiitity (,-YejieratorOtily((..iejiej-ates2OOlbs oi-ignore/.ii.iontil). <br /> F1 Large Quantity Generator with 011 site Treatnient(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 /> Signattire: <br /> —'Title: <br /> Ef I D 45-03 4 <br /> 10/6/2003 <br />