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0 0 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: 94' t ,wvq w4i <br /> Generator Facility Address: 1+4,,A,, L <br /> —V10 I <br /> City I State Zip Code <br /> Phone Number: <br /> Generator Mailing Address: <br /> City State Zip Code <br /> Type of Business: S k,uey,) jVA"I f 4C, fi�G,(- l <br /> Authorized Representative: eAbb'-w-ri <br /> Title: —A0,U-/V(S <br /> Emergency Phone Number: (510 <br /> REGISTRATION FOR: <br /> F] Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> D< Large Quantity Generator Only(Generates 200 lbs or rnore/rnonth). <br /> "S' <br /> E] 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 /> r. <br /> Signature: Title: id <br /> Date: '/1411 <br /> EMD 45-03 4 <br /> 2015` <br />