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Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: MA 01 ere <br />Generator Facility Address: r25oS' �, ,a �,� a.✓! <br />a ry ,r"e rv,✓ n 9 Sa o 9 <br />City State Zip Code <br />Phone Number: (209 ) D --S---500/ <br />Generator Mailing Address: ,,,ja,,fe <br />City State Zip Code <br />Type of Business: W ra 1 e a L a FF 1C.6- <br />Authorized <br />C.Authorized Representative: kATp. r �J A Wol lm S Z /i'i 74 &d <br />Title: A D V%X 1 01 S TRA?t OAZT S ot.rc, 7rbg L'z,.iu.o Z. <br />Emergency Phone Number: (?0 9 ) 4--/T - -7205( <br />REGISTRATION FOR: <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 />J <br />l <br />: §-z7" ay <br />