Laserfiche WebLink
Registration Medical se <br /> For Generators of Medical Waste <br /> GENERATOR NAME: L-t"Jco fbST-AWTOE con.E <br /> Generator Facility Address: 10V . 1.jc,-r E-r <br /> 4,'b CA �1S2o 3 <br /> City State Zip Code <br /> Phone Number: ( Zoq ) t 6941 <br /> Generator Mailing Address: s E As A rz <br /> City State Zip Code <br /> Type of Business: mow' t•A "C.u`..,- !j <br /> Authorized Representative: 5ej-z NMR. <br /> Title: A + t 5T oR <br /> Emergency Phone Number: ( ) l W- •SSR <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 2001bs/month). <br /> v� Large Quantity Generator Only(Generates 200 lbs or more/month). <br /> ❑ Large Quantity Generator with Onsite Treatment(Generates 200 lbs or snore/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: r` -r4. Title: AOMWITCCAMCA- Date: fa[->I I3 <br /> EHD 45-03 4 <br /> 10/6/2003 <br />