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Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Busin s Name: <br /> Business A ress: <br /> City State Zip Code <br /> Phone Number: ( ) <br /> Contact Person: <br /> I am not required to register a\atmy <br /> te Generator because: <br /> Please check the appropriate statem <br /> ❑ I do not generate any <br /> ❑ I generate less than 2dical waste per month. <br /> ❑ I do not treat any meility 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 know ge and belief, I do not generate or <br /> store any of the wastes specified on the"Pre-Application Q stionnaire" as regulated medical <br /> wastes in an amount that equals or exceeds 200 pounds per mo <br /> ❑ I declare under penalty of law that I will not be treating any amount o egulated medical wastes <br /> at my facility by way of autoclaving, incinerating or microwaving. <br /> Signature: Title: Date: <br /> EHD 45-03 3 <br /> 2015 <br />