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10/14/2013 18:13 2092394 MANTECARM PAGE 05 <br /> Registratlon for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: <br /> Generator Facility Address: <br /> City State Zip Code <br /> Phone Number: 69 1 jef,-1 2— <br /> Generator Mailing Address: 'S AM C,,S I-A-06 <br /> City statc Zip Code <br /> Type of Business: W <br /> -- <br /> Authorized.Representative: <br /> jAuthorized.Representative: JAY(' ( I t, <br /> Title: 1 V1 f,5 <br /> Emergency Phone Number: <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 Quantify Generator <br /> 9 With Onsite Treatment(Generates 200 lbs or morehnonfli). <br /> I declare under penalty of law tj)at 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 Actandincidental to the issuance of this registration and the operation <br /> of this business. <br /> Signature: <br /> 1,itle: D ate: <br /> E-M 45-03 4 <br /> Received Time Oct, 14. 2013 6: 14PM No. 0850 <br />