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I % % <br />CERTIRCA77ON <br />NOT REQUIRED <br />or Print) <br />BUSINESS <br />EVA <br />PHONE <br />r <br />• <br />NAME OF RESPONSIBLE PERSON: <br />State zip <br />I Am Not Required To Register As A Medical:ne • <br />[Pleasei r <br />•. notgenerate any medical <br />generate less than00 pounds ofmedical waste per • <br />I do not treat any medical waste at my facility by means of autoclaving, <br />incinerating ! ;microwaving. <br />Please Indicate The Appropriate Statement(s): <br />I declare under penalty of law that to the best �fmy knowledge and belief, I do not <br />generate or store any of the wastes specified on the 'Pre -Application Questionnaire-" <br />as "Regulated Medical Wastes" m*l an amount over 200 pounds per month. <br />SIGNATURE: DATE: <br />