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Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: A '!/f4 A4 6 ni P e. <br />Generator Facility Address: -WI, _nUf6l"IN STVIIE-T <br />STC(P-T90 (A <br />Phone Number: CI State Zip Code <br />Generator Mailing Address: L I fq � 141 {N S I IZEE,—F <br />�Irocvl-o tj CI§M 2 - <br />city Stale Zip Code <br />Type of Business: -riAPCO 1, <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <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 />E] 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: <br />Ell <br />