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E7; <br />L 11,11, v <br />0100"W� <br />1100:1071,111ii'll, 1� i <br />City 5+0C A Zip 2�2�0 1 <br />- , 4 LC) state <br />Phone Number (;,o cA q 7 7 - 7., &f <br />Street 66, -Mc o -b U boue, <br />City State _ Zip <br />TYPEOFBUSINESS: Co vty es c y r H—o5 10L <br />AUTHORIZED REPRESENTATIVE: <br />TITLE: <br />RMERGENCY PHONE NUMBER: 0r ) Af 7 7 <br />low <br />lot, • <br />Small Quantity Generator With Onsite Treatment. (Generates < 200 <br />Large Quantity Generator Orgy. (Generates 200 or more <br />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 hereby consent 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: r <br />TITLE:A:,Pw,,-t4 DATE: 10-11-2t <br />