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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: <br /> Generator Facility Address: I'Z O'S' <br /> "or,+e C-A CA <br /> City State Zip Code <br /> Phone Number: 7-001 <br /> Generator Mailing Address: -17-0s <br /> M oiY4--e t--)k C& 9573 3 <br /> City State Zip Code <br /> Type of Business: <br /> Authorized Representative: <br /> Title: i c-e 3 <br /> Emergency Phone Number: Lzp,' <br /> REGISTRATION FOR: <br /> El 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 IN 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 /> Signature: &a!( <br /> E-M 45-03 <br /> 2015 4 <br />