Laserfiche WebLink
Registration ick. Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: S 01 C U \ �)«uyS�S — T im, <br /> Generator Facility Address: 7156 W QST CR-"\V\nC VL-O- 5Lkmt ty� <br /> N"r y3�� <br /> City State Zip Code <br /> Phone Number: <br /> Generator Mailing Address: t1% W C,ST C(Lfk(11 \,\O e Rr}. M1�-e b <br /> City State Zip Code <br /> Type of Business: n 1l}1 q Se S Ca U1T� <br /> Authorized Representative: rnw-- S Y-M C- <br /> Title: I- Ak CA A Y) <br /> Emergency Phone Number: ( U9 <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: 0fY1 fi�Y\i fkh Date: tbb:12,015 <br /> EHD 45-03 4 <br /> 2015 <br />