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GENE RATOR NAME: —. i` cblsiL-�LL�— <br />Generator Facility Address: <br />08- <br />Phone Number: city State Zip Code <br />Generator Mailing Address: IeA <br />State Zip Code <br />Authorized Representative: C, <br />Title: C CcKk—) <br />Emergency Phone Number: mn.) CO -A 2:7-2— <br />❑�Sn 11 Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br />Large Quantity Generator Only (Generates 200 lbs or more/month). <br />El 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 <br />2015 4 <br />N <br />