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Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: 1_ — <br />Generator Facility Address: 5 <br />City State Zip Code <br />Phone Number: (`� ) q 4 ` 4 <br />Generator Mailing Address: <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />REGISTRATION FOR: <br />City State Zip Code <br />"h H <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: <br />EHD 45-03 4 <br />10/6/2003 <br />Title: <br />