Laserfiche WebLink
t <br /> REGISTRATION <br /> FOR GENERATORS OF MEDICAL WASTE <br /> GENERATOR NAME <br /> GENERATOR FACILITY ADDRESS <br /> Street <br /> City State Zip <br /> Phone Number <br /> GENERATOR MAILING ADDRESS <br /> Street <br /> City State Zip <br /> TYPE OF BUSINESS <br /> AUTHORIZED REPRESENTATIVE <br /> TITLE <br /> EMERGENCY PHONE NUMBER <br /> REGISTRATION FOR: <br /> Small Quantity Generator with onsite treatment (Generates less than 200 lbs/month) <br /> Large Quantity Generator Only (Generates more than 200 lbs/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 <br /> herein are correct and true. I hereby consent to all necessary inspections made pursuant to the <br /> California Medical Waste Management Act and incidental to the issuance of this registration and <br /> the operation of this business. <br /> SIGNATURE TITLE DATE <br /> 4 <br />