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1 <br /> 0 <br /> Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: <br /> Business Address: a <br /> o e ®aa�e rcl a eLA <br /> City State Zip Code <br /> Phone Number: <br /> Contact Person: <br /> ay- <br /> I am not required to register as a Medical Waste Generator because: <br /> 10 <br /> Please check the appropriate statement(s) <br /> ❑ I do not generate any medical waste. <br /> ❑ I generate less than 200 pounds of medical waste per month. <br /> ❑ I do not treat any medical waste at my facility by means of autoclaving,'incinerating or <br /> microwaving. <br /> ❑ Other: <br /> Please indicate the appropriate statement(s): <br /> ❑ I declare under penalty of law that to the best of my knowledge and belief, I do not generate or <br /> store any of the wastes specified on the"Pre-Application Questionnaire" as regulated medical <br /> wastes in an amount that equals or exceeds 200 pounds per month. <br /> ❑ I declare under penalty of law that I will not be treating any amount of regulated medical wastes <br /> at my facility by way of autoclaving, incinerating or microwaving. <br /> Signature: Title: Date: <br /> EHD 45-02-003 Page 3 of 7 <br /> 10/6/2003 <br />