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Registration Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: <br /> Generator Facility Address: f:7re.-5uo AVc, <br /> 5 k-0 cuoa CA, <br /> City State Zip Code <br /> Phone Number: L009 ) 4 b 7 3 3 <br /> Generator Mailing Address: t>oa ` Fre:>mQ, — <br /> City State Zip Code <br /> Type of Business: 'a <br /> Authorized Representative: 'L `� <br /> Title: <br /> Emergency Phone Number: (T-or, <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 /> 44— <br /> Signature: Title: Date: N <br /> EHD 45-03 4 <br /> 2015 <br />