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0 0 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME; °► t? - . <br /> Generator Facility Address: 1 t` j <br /> City d k. <br /> State Zip Code <br /> Phone Number: f2oq-A-W, <br /> Generator Mailing Address: _-- <br /> City F state Zip Code <br /> Type of Business: 1 t <br /> Authorized Representative: c, 1C <br /> Title: <br /> Emergency Phone Number: on 4Lon <br /> REGISTRATION FOR: <br /> El Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> Large Quantity Generator Only(Generates200lbs 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 /> Siggnature. Title: <br /> D t <br /> i <br /> I <br /> i <br /> EMD 45-a3 4 <br /> ta/ s <br /> a <br /> i <br />