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SAN 1 O A Q U I N Environmental Health Department <br /> - COUNTY -- <br /> Registratio or Generators of kledical Wagte <br /> Generator Name : "�3R A � . � � � t, L1L ,v\ ta�-40 a --ta -1�o /) <br /> Generator Facility Address : �� 3g 9 � C- a- � ocn % <br /> City State Zip Code <br /> Phone Number : (�- jCj ) <br /> Generator Mailing Address : `.._7 a ,fV1 R- <br /> City State Zip Code : <br /> Type of Business : � LA. c !j tF C =:1 <br /> Authorized Representative : : C� ac' `�1 f`!-1 <br /> Title : cc 'a : cJCS Ma."v� a l' <br /> Emergency Phone Number:a2% Cj Lj (4 cl I aU <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 : f — Title : 1����r� S �� vi Date : 3 zy�z <br /> 5of11 <br />