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Registration s <br /> For Generators of Medical Waste <br /> GENERATOR NAME: D(CNOve \s -- T iIAN <br /> Generator Facility Address: 21ST W VS'l GV-M 1\K 0D. SLktTZ 1yib <br /> r¢ cel c �y3IT <br /> Citi' State Zip Code <br /> Phone Number: 7f � ) <br /> Generator Mailing Address: `L 1 5�6 w CST C Vu X11 L 1 o e (L7. SLmrF 5"b <br /> City State Zip Code <br /> Type of Business: �1RLaSl� C\1,1T <br /> Authorized Representative. <br /> Title: I o tY1 1C1. r�`cI AYI <br /> Emergency Phone Number: ( U9 ) 'L q 31 q <br /> REGISTRATION F <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:0101'&N '�6,tilyl Qfkll Date: Qom,/QC�zdZc <br /> EHD 45-03 4 <br /> Inti <br />