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Registration Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: i nC C c� <br /> Generator Facility Address: 1 t✓n �r }. <br /> City State Zip Code <br /> Phone Number: ( ) 1 <br /> Generator Mailing Address: _ <br /> City State Zip Code <br /> Type of Business: �Y,i\\ .A.rsi r-) <br /> Authorized Representative: <br /> Title: , <br /> Emergency Phone Number: (CQ-0q ) LhoLo ®5,341 t 1 <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment (Generates less than 2001bs/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: r I MKAW Date: 4- <br /> EHD 45-03 4 <br /> 2015 <br />