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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: M10 u �� ra='t p,•� <br /> Generator Facility Address: -2-3ce 6 Q�Zf-F o t n <br /> City State Zip Code <br /> Phone Number: )Ct L(4 - ( ® <br /> c <br /> Generator Mailing Address: <br /> 04A�46 952-P Lf <br /> City State Zip Code <br /> Type of Business: 54,.e-c-e_t�--►"R <br /> Authorized Representative: tt 'a Cr e <br /> Title: d M` <br /> Emergency Phone Number: (2.09 ) <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> lk 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 /> tja <br /> Signature. Title: ate: <br /> EHD 45-03 4 <br /> 10/6/2003 <br />