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Registration Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: _ e_A Lt e Di As j-51 <% <br /> Generator Facility Address: LUC � <br /> City State Zip Code <br /> Phone Number: ( ) <br /> Generator Mailing Address: 5cl Me <br /> City State Zip Code <br /> Type of Business: C—U VN( G- <br /> Authorized Representative: f it i f ey1`Z. <br /> Title: -T et,k n'%L rd k rr v k' S-o <br /> Emergency Phone Number: <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: <br /> voxj)ate: <br /> i <br /> EHD 45-03 4 <br /> 10/6/2003 <br />