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• • <br /> SA N 10 A Q U I N Environmental Health Department <br /> -- - <br /> COUNTY---- <br /> Registration for Generators of Medical Waste <br /> Generator Name: ���- S�errs �l�l ys!S L+u-►�✓ <br /> Generator Facility Address: 4SO o <br /> Sk C.,V Lm <br /> City State Zip Code <br /> Phone Number: ( Z° S(o — UN <br /> Generator Mailing Address: sem°"'-' <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: �` � CL{ N7�--�'�-o•JNc��- G�.w✓ <br /> Title: CST <br /> Emergency Phone Number: (U--1 <br /> Registration for: <br /> ❑ Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br /> Olarge 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 <br /> made herein are correct and true. I hereby consent to all necessary inspections made <br /> pursuant to the California Medical Waste Management Act and incidental to the issuance of <br /> this registration and t e operation of this business. <br /> Signature: �` Title: T* Date: ?iIZS�ZvZp <br /> aors <br />