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1 <br /> .GISTRATION FOR MEDICAL <br /> (Please Type or Print) <br /> GENERATOR NAME: i <br /> GENERATOR FACI ADDRESS: <br /> Street 1 l Ave- <br /> city twtpra State CA Zip <br /> Phone Number J ) 1 <br /> GENERATOR MAILING ADDRESS: <br /> Street x.:12`? �L j \/ <br /> city MW State Zip <br /> TYPE OF BUSINESS: I t <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: D I f f C r of Lu f c a <br /> EMERGENCY PHONE NUMBER: ( ) ISCI Z <br /> REGISTRATION FOR: <br /> (Check One) <br /> O Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> ( Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> O Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) <br /> I declare under penalty of law that to the best of my knowledge and belief the statements <br /> made herein are correct and true. I herebyconsent to all necessary inspections made <br /> pursuant to the California Medical Waste Management Act and incidental to the issuance <br /> of this registration and the operation of this business. <br /> SIGNATURE: ��JffjjMA / 1 J <br />