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�11 dM4 I #I NU UQ I [7nnI <br />GENERATOR NAME: wu(-Vj-e� I-- 4L4�� cz,-A, <br />Generator Facility Address: <br />co 1?5-3 <br />city State Zip Code <br />Phone Number: <br />Generator Mailing Address: <br />City State Zip Code <br />Type of Business: 2EU:-d&k ",tmte <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: ) --73 <br />El Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/rnonth). <br />RI Large Quantity Generator Only (Generates 200 lbs or morelmonth). <br />El Large Quantity Generator with Onsite Treatment (Generates 200 Ibs 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 aU necessary inspections made pursuant to the CaNfornia <br />Medical Waste Management Act and incidental to the issuance of this registration and the operation <br />of this business. <br />EHD4"3 <br />2015 <br />2 <br />