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e A <br /> Registration r Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: Liy\e4A Squav, 45f &AU� <br /> Generator Facility Address: (®32 4. Llh4dn CStrett <br /> sk <br /> City _s3q! State Zip Code <br /> Phone Number: ( 2A ) <br /> Generator Mailing Address: r GtbnuQ, <br /> City" �^ � State Zip Code <br /> Type of Business: St� UtSi Twit <br /> Authorized Representative: K1. 066W <br /> Title: .S <br /> Emergency Phone Number: ( 2A ) 42Zl <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 /> ------------ Signature: ----- --- - "��- ----- Title: Date: <br /> EHD 45-03 4 <br /> 10 /2903 <br />