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0 • <br /> Registration for Medical Waste <br /> For Generators of Nledical Waste <br /> GENERATOR NAME: NE7ALTHCA-ee- 51-6C:KrotJ <br /> Generator Facility Address: ( C?l k4,,�ecp LN h - loo <br /> sro C K-J-CN, (A-. 9y zly <br /> City State Zip Code <br /> Phone Number: ( ?.GY'r' ) q fl-0(0 <br /> Generator Mailing Address: l t'd l � MA-96N I J✓ x,100 <br /> 57-oCKr6111, r4 9SZID <br /> City State Zip Code <br /> Type of Business: PIOLY515 (LAN/G <br /> Authorized Representative: JA-06S 161(\J6 <br /> Title: 010MC9iCA-L Te-cj4N t CtA-oJ <br /> Emergency Phone Number: ( ZGg ) L22 1035 Hapll-C PSN eF <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br /> -17 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 /> S gnc re: Title: Date: 11/CS//T <br /> i <br /> EHD 45-03 4 <br /> 10-6%2003 <br />