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11 <br />19 `' 1 1 ' 1 <br />o •ri <br />1.-0WM MINto] :7eF_1U1x <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 />rRX" &II719CI7►•a[I] <br />C', <br />In CA 5 7-04 <br />cityState Zip Code <br />LMI 40 - 1 <br />IM0 WCAL&foia *ee+ <br />City State Zip Code <br />ea �ffi Uric, <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. <br />EHD 45-03 4 <br />10/6/2003 <br />9 <br />