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0 0 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: M aA,4 2C. <br /> Generator Facility Address: �llU �'c�� i W xv c- <br /> tvW,,&�-eco, CA <br /> City State Zip Code <br /> Phone Number: ( ) <br /> Generator Mailing Address: S e CA-5 rcb"e- <br /> City State Zip Code <br /> Type of Business: 5 k:;t1-eA A.us:5 t` g Fcr`l vT Y l,5 kr rf 7&P,- �, r <br /> Authorized Representative: Wt b-ewte,5c�- <br /> x <br /> Title: t�d'AaernL S. y' <br /> Emergency Phone Number: ( got ) aZ3 9- I 2z2 <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 2001bs/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 Mana ment Act and incidental to the issuance of this registration and the operation <br /> of this business. <br /> j n <br /> Signature: Title: Date: <br /> EHD 45-03 4 <br /> 2015 <br />