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am <br />WIMM-M IN <br />Generator Facility Address: klic "M -LM,-vMkrxQQ, <br />city Stat Zip Code <br />PhoneNumber: <br />Generator Mang Address: <br />Cft <br />city state code <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />11IMMUZ7,11- <br />❑ Small Quantity Generator with Onsite, Treatment (Cmerates less than 200'lbs/month). <br />Large Quantity Generator Only (Generates 200 lbs or more/month). <br />❑ Large Quantity Generator with Onsite Treatment (0enerates 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 caiifornia <br />Medical Waste Mauagement Act and incidental'to the issuance of this registratio'n and the operation <br />of this business. <br />Signature: <br />MM45-03 4 <br />,M4003 <br />M <br />