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GENERATOR <br />City State Zip <br />City State - Zip <br />TYPE OF BUSINESS: <br />AUTHORIZED REPRESE <br />TITLE: <br />iMERGENCY PHONE NUMBER: <br />11,12M10 - • 01. <br />• <br />Small Quantity GeneratorOnsite Treatment.200 r • <br />Large Quantity GeneratorOnly. /1 or mores <br />Large Quantity Generator With Onsite Treatment.11 or more <br />I declare under penalty of law that to the best of my knowledge and belief the statements <br />madc- <br />pursuant to the California -r • incidental to <br />the issuancl; <br />of this registration and the operation of this business. <br />SIGNATURE:DATE: <br />0 <br />