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REGISTRATION FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: . _)/Pat el/X/ 6?12 <br /> GENERATOR FACILITY ADDRESS: <br /> Street /f/ f <br /> City State Zip cl"� ,1 — <br /> P <br /> Phone Number 161 <br /> GENERATOR MAILING ADDRESS: <br /> Street <br /> City Stat ip <br /> TYPE OF BUSINESS: 'Ala, <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: <br /> EMERGENCY PHONE NUMBER: fzm <br /> REGISTRATION FOR: <br /> (Check One) <br /> (c)-' Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> ( ) Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> ( ) Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) <br /> I declare under penalty of law that to the best of my knowledge and belief the statements <br /> made herein are correct and true. I hereby consent to all necessary inspections made <br /> pursuant to the California Medical Waste Management Act and incidental to the issuance <br /> of this registration and the operation of this business. <br /> SIGNATURE: TITLE: DATE: a <br /> 6 <br />