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0 0 . I., <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: Tt& D m n <br /> Generator Facility Address: alYmy '' q- e �. <br /> T at <br /> C' State Zip Code <br /> Phone Number: ( ) 319,�/� <br /> Generator Mailing Address: 1' <br /> City State Zip Code <br /> Type of Business: <br /> L& <br /> Authorized Representative: <br /> Title: J �, <br /> Emergency Phone Number: ( ) 71 <br /> REGISTRATION FOR: <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: Title: ) Date: i 7 <br /> k,�, <br /> EHD 45-03 4 <br /> i ni�nnnz <br />