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0 0 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: IeA <br /> U <br /> Generator Facility Address: <br /> City State Zip Code <br /> Phone Number: 1--L ) L/-73 62W <br /> Generator Mailing Address: SAC,&5 06c, <br /> City State Zip Code <br /> Type of Business: DICA!ISIS CJIAIC— <br /> Authorized Representative: I <br /> Title: PIfnnW&CeJ 1�-g Ina& <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 "` ---�� Title: <br /> ERD 45-03 4 <br /> 2015 <br />