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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: .24N\ y iYt ; <br /> Generator Facility Address: <br /> City State Zip Code <br /> Phone Number: (14 09 ) L-� Q E(O a\ <br /> Generator Mailing Address: �$ l A�QS-� <br /> 3 C1 <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: �A <br /> Title: SLS Y C YI A,\ O \- -,k <br /> Emergency Phone Number: <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 2001bs/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 /> 13 <br /> Signature: Title: Date: - <br /> EHD 45-02-003 Page 4 of 7 <br />