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1' <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: ���5 '�^��'1C�f1R:Y1 <br /> Generator Facility Address: �'� k '(� <br /> cfi <br /> City State Zip Code <br /> Phone Number: <br /> Generator Mailing Address: <br /> t � ' �- <br /> city State Zip Code <br /> Type of Business: ��ebc �Gx In ��yiiC <br /> Authorized Representative: �fv� 1�i•1 � <br /> Title: l <br /> Emergency Phone Number: ) T (0 n. 2 <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> 1Large 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: �5 Dater <br /> E1,1D 45-03 4 <br /> i 3nrF�7nm . <br />