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E <br />C <br />Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: 1 _ ' <br />+o <br />Generator Facility Address: 4'-IintA <br />a�h,,4.c-K.Ci <br />t <br />City State Zip Code <br />Phone Number: ( ) U2711 <br />Generator Mailing Address: <br />City State Zip Code <br />Type of Business: hy'Atd V WW%Ny ac \) <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />REGIS'T'RATION FOR: <br />❑ 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 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 />EHD 45-03 4 <br />2015 <br />