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0 <br />• <br />Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: s+D e -k �Lo', Ju ,i G vt L'/ <br />Generator Facility Address: <br />S-4) 414k,)11 C A <br />City State Zip Code <br />Phone Number: ( ; `l <br />Generator Mailing Address: s� fl, -e— <br />city State Zip Code <br />Type of Business: <br />Authorized Representative: %4o At, -1 JS'u <br />Title: <br />AdM int <br />f-1-1 � el' - <br />Emergency Phone Number: 07 ) <br />52 3 — 7 <br />z d V / <br />— <br />REGISTRATION FOR: <br />2-1"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 />t�L- <br />EHD 45-03 4 <br />10/6/2003 <br />�' Jt'=Date: <br />