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Registration Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: ��° p ►``� 11'ht a (�' C <br /> Generator Facility Address: YJ - �"� I <br /> _ S�Tp CA <br /> City State Zip Code <br /> Phone Number: ( Drb-'A ) GS - -3 a 6 <br /> Generator Mailing Address: 1 J�D D ('tom o, S- e'ee+ <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: \Inh <br /> Title: "eni 6'r SvG Ni(' r,Sue ea-y-t S,e4v;Gt.S <br /> Emergency Phone Number: (`nl 0 — <br /> REGISTRATION FOR: <br /> [] all 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:&eviDf Sv"v Af A Date: <br /> EBD 45-03 4 <br /> 10!6(2003 <br />