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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: 51F0cie-foO Pef,40JAL CARE C60102-- <br /> Generator Facility Address: b0i 0. CAU,fD- MN STVEE;-r <br /> a k q <br /> qW--roN (Ift <br /> Ci State Zip Code <br /> Phone Number: 2� ) qocq- 20115 <br /> Generator Mailing Address: 601 N, chulf-V <br /> -�-row-o 0 ON C15 U 2, <br /> City State Zip Code <br /> Type of Business: Ijc 9 A L- OT Hr <br /> Authorized Representative: 0 1 T-0 4A <br /> Title: fto R 61 EL- <br /> Emergency Phone Number: ( Oq ) 40p- 0075 <br /> REGISTRATION FOR: <br /> El 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: Date: <br /> EHD 45-03 4 <br /> 2015 <br />