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RE G TION FOR MEDICAL <br /> (Please Type or Print) <br /> GENERATOR E: <br /> GENERATOR FACILITY ADDRESS: <br /> Street <br /> City State Zip <br /> Phone Number C ) <br /> GENERATOR MAILING ADDRESS: <br /> Street <br /> City State Zip <br /> TYPE OF BUSINESS: <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: <br /> EMERGENCY PHONE NUMBER: f <br /> REGISTRATION FOR: <br /> (Check One) <br /> O Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> O Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> OLarge Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) <br /> I declare under penalty of law that to the best of my knowledge and belief the statements <br /> made herein are correct and true. I hereby consent to all necessary inspections made <br /> pursuant to the California Medical Waste Management Act and incidental to the issuance <br /> of this registration and the operation of this business. <br /> SIGNATURE: DATE: <br /> 6 <br />