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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: f a L ` , �'S COL <br /> °r <br /> Generator Facility Address: -,S-4S l L <br /> 7f eI iSI (� <br /> City State Zip Code <br /> Phone Number: 60 L I1f <br /> Generator Mailing Address: r <br /> City State Zip Code <br /> Type of Business: `` ( <br /> Authorized Representative: <br /> Title: A dent,-,d�f(c-.4-D-u <br /> Emergency Phone Number: ( �` 0't ) 'O{� <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> tO 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 /> Signature: ��' Title: A O� 04114- Date: 3141/0 <br /> J�j G 9(1"e,4,:4 <br /> EHD 45-03 4 <br /> 10/6/2003 <br />