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� 1 <br /> Registration Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: y, 5v le , V) / 4 v`-^ D6fta <br /> Generator Facility Address: A.VX e_ <br /> CA 61 ,52-4-0 <br /> City State Zip Code <br /> Phone Number: <br /> Generator Mailing Address: '70 °c c's AC <br /> i-O t�j, C A �- <br /> Cit%l State Zip Code <br /> Type of Business: AAJO � <br /> Authorized Representative: evk DS <br /> Title: S <br /> Emergency Phone Number: ( 6 ) � <br /> REGISTRATION FOR: <br /> 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: `'" S Date: o�Z�311i <br /> EHD 45-03 4 <br /> 10/6/2003 <br />