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Oct. 9. 2015 10: 03AM No- 6392 P. 2 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATORNAME: <br /> Generator Facility Address: �E. on Y1e� <br /> CA 152.ar2- <br /> Phone Number: <br /> City State Zip Code <br /> Generator Mailing Address: C). <br /> City (t State Zip Code <br /> Type of Business: �. CD `r M U-ar'1t i n) (:=, <br /> Authorized Representative: CqGrC-i-c— <br /> Title: e'rI G YfIa-Yl'q-- <br /> Emergency Phone Number: 2001 H O(D " , <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. Y 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 /> oe <br /> Si�atuxe: Ok Title: Date: 9 b l 1 <br /> Received Time Oct, 9, 2015 10 : 07AM No, 1383 4 <br /> 2015 <br />