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• <br />E <br />Registration for Medical Waste <br />For Generators of Medical Waste <br />GENERATOR NAME: on <br />tV <br />Generator Facility Address: 1 <br />B -f W Q <br />q5,;�fj <br />tyd 5D -141 � State Zip Code <br />1� <br />Phone Number: j� �('� I <br />4 <br />Generator Mailing Address: U) M I,11'�, E �.1- <br />� i)45f o CA <br />City State Zip Code <br />Type of Business: <br />Authorized Representative: <br />Title: <br />Emergency Phone Number: <br />REGISTRATION 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 />ray LI/I <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 />11 <br />Signature: <br />Z <br />EHD 45-03 4 <br />10/6/2003 <br />fLA&JI - C> P5, <br />MAf-JA6CJL- Date:I <br />