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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: 3AF6Ui-1-Z- ��t-pLy-HWE — Wc5l <br /> Generator Facility Address: Lo. Ci�AtJ7— L11,J0 4D. 5 rr. /9-0 <br /> 1-9-h-cy, CA- 9�3- -t-7- <br /> City State Zip Code <br /> Phone Number: 1�/ ) ?�k T 1-25,9 9 <br /> Generator Mailing Address: 2S1.d, NZAfrf-U11,16 90 57—t- 1✓� <br /> L WCYp <br /> C4. <br /> City State Zip Code <br /> Type of Business: r)IA-UY515 U//J�C- <br /> Authorized Representative: --/#Me7-5 X-<fj& <br /> Title: PlOdIE7211CAL e )C-IkfJ <br /> Emergency Phone Number: Z-4�-10 140&ILr- <br /> REGISTRATION FOR: <br /> E] I Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> Large Quantity Generator Only(Generates 200 lbs or more/month). <br /> C� <br /> F-j 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 /> Sign dire: Title: 19. F <br /> Date: <br /> EHD 45-03 4 <br /> 10/6,,2003 <br />