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GVENERATOR NAME: 5 -roc le -fl) 0 (IUMMI, <br />Generator Facility Address: CAUID-MN STVEE;-r <br />qW--roN Ch <br />Ci State Zip Code <br />Phone Number: 2� ) 1i 01 <br />20115 <br />I F Mj IVII <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />60 1 N, CJ 9-eE77 <br />51W-0 <br />city State Zip Code <br />N�Jcg A <br />El 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: <br />EHD 45-03 4 <br />2015 <br />