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MEDICAL WASTE PROGRAM <br />Business <br />Name I, ' <br />Phone <br />3 -- <br />Business <br />Address ZqoT(,�', . �(�vim_ �.. <br />CXv City <br />%ods. Zip sz <br />Contact Person H en Phone <br />Owner lo+&A Phone <br />Owner Address i'0 'FSc Zc7J - City is c���,r� Zip <br />Program Element Code LIL3O <br />Record ID # PR L,5C)Lc)Q 1 <br />Onsite Treatment? Y (circle) —� <br />LQHE? Y (circle) <br />MWMP in EHD file? N (circle) <br />If Yes,Treatment Unit Type <br />