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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: <br /> Generator Facility Address: _W1 -Aljfb"IN STVIIE-T <br /> STC(P-T90 (A__q 54k <br /> Phone Number: Ci 0015 State Zip Code <br /> Lb? <br /> Generator Mailing Address: bOl N. ChLl � i4l {N S I iZ EE,-F <br /> tj "15M 2- <br /> city Stale Zip Code <br /> Type of Business: riA PC 9 A 1, OV H <br /> Authorized Representative: Te- <br /> Title: <br /> Emergency Phone Number: ( �Oq ) 140 tv 0075- <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 /> 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: Title: Dilte., <br /> JEW45-03 <br /> li <br /> 2015 4 <br />