Laserfiche WebLink
Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: � ccaydws M&h&re <br /> n <br /> Generator Facility Address: '� �� k '✓ <br /> D&V -OY <br /> O— ® cS O <br /> I State Zip Code <br /> Phone Number: oh qG—7' <br /> AAS bq <br /> Generator Mailing Address: C l o _ <br /> Of-v- � L <br /> City State Zip Code <br /> �a �A <br /> Type of Business: U <br /> Authorized Representative: <br /> 0 K-L V� <br /> Title: eQ <br /> Emergency Phone Number: ( U ) ` s <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> 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 /> e <br /> Signature: Title: Date: <br /> EHD 45-03 4 <br /> 10/6/2003 <br />