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REGISTRATION FOR MEDICAL WASTE <br /> (Please Type or Print) <br /> GENERATOR NAME: WlD r j�jj� PD S-E � Theo- 617 11/I-e7D/c <br /> GENERATOR FACILITY ADDRESS: <br /> Street �� ` I S A610 L AWL <br /> City State r Zip 5� ��-- <br /> Phone Number <br /> GENERATOR MAILING ADDRESS: <br /> Street -DPt tL C5-- <br /> City State Zip <br /> TYPE OF BUSINESS: 10A-L F-F(C �= <br /> AUTHORIZED REPRESENTATIVE: <br /> TITLE: M D <br /> EMERGENCY PHONE NUMBER: ( ) J)Y&cf: <br /> REGISTRATION FOR: <br /> (Check One) <br /> Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br /> ( ) Large Quantity Generator Only. (Generates 200 or more lbs./mo.) <br /> ( ) Large Quantity Generator With Onsite Treatment. (Generates 200 or more lbs./mo.) <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 <br /> of this registration and the operation of this business. <br /> SIGNATURE:Ci4�1� 0, � TITLE: 1�� DATE: 6 <br /> 6 <br />