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Registration for Medical Waste <br />For Generators of Medical Waste <br />Generator Facility Address: <br />Phone Number: <br />Generator Mailing Address: <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />• <br />h's fU eek i ccd Qtv4v <br />a <br />I'M � o' al &-k-c-ec-f- <br />SNcta-ri>1 e. A- CI 5Dt �-] <br />City 1) 4 �� _ , i State Zip Code <br />City we4State Zip Code <br />viii V—P. le, <br />SefVice ft.^tt\- <br />( ) 4(0--- &4'1-1 <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:-(�\\% D)"\,Date: Om ( <br />EHD 45-03 4 <br />10/6/2003 <br />