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Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR N ��� <br /> Generator Facility Address: �/V <br /> C1- <br /> City <br /> State Zip Cade <br /> Phone Number: f city <br /> o2 35T- /0-0-z- <br /> Generator Mailing Address: <br /> City State Zip Code <br /> Type of Business: (Sl�� /U A <br /> I <br /> Authorized Representative: ULV . "— <br /> Title: <br /> Emergency Phone Number: <br /> REGISTRATION FOR: <br /> ❑ Small Quantity Generator with Onsite Treatment(Generates less than 200 Ibs/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 /> +A f w <br /> Signature: L/ Title: 4 Acnsa=4 Date: <br /> EM 45-03 4 <br /> 1002003 <br />