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I Jan, 31. 2012 10:32AM <br />GENERATOR NAME: <br />G.11L D MEDICAL ENGINEERING No. 5494 P, 5 <br />w <br />Re9" *stration for Medical Waste <br />For Generators of Medical Waste <br />Generator Facility Address: <br />Phone Number: <br />Generator Mailing Address - <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />61 on <br />McY,Atn <br />Ammw &P� q Wj <br />ty — state Zip Code <br />LN) 4174 <br />uo CLK& <br />UMP5fn 35D <br />I City State Zip Code <br />L] 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 />*I% 't <br />EHD 45-03 4 <br />10/6/2003 <br />le <br />