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t <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: .' 'r <br /> Generator Facility Address: <br /> l <br /> City State Zip Code <br /> Phone Number: ( ° oq ) <br /> Generator Mailing Address: <br /> City State Zip Code <br /> Type of Business: Mei 1 C e" C,f "u,k- L � <br /> Authorized Representative: �—D® `r 1 S C (Gl i <br /> Title: V SAN N,C e r <br /> Emergency Phone Number: ( ) j <br /> REGISTRATION FOR: <br /> 14 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: Date: <br /> EHD 45-03 4 <br /> 10/6/2003 <br />