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- , b 1 0 0 7 <br />Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: <br />Generator Facility Address: <br />Phone Number: <br />Generator Mailing Address <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />Tro C � OSI' W3� �) <br />City „ A,,\ V State Zip Code <br />i <br />City <br />Cf ���6��—�`�� <br />State <br />Zip Code <br />fl< <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 />r <br />c <br />Signature: Title: Date: Az��T <br />HID4�-o=-OW %\ ch Page 4 of 7 <br />u: 1.1417 <br />