Laserfiche WebLink
E <br />CJ <br />CERTIFICATION STATEMENT <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL <br />NOT REQUIRED TO REGISTER <br />(Please Type or Print) <br />HLALTH <br />WASU� RS <br />Street A STV t-ln— <br />city SM State zip q'S 2__LLCZ <br />PHONE NUMBER: <br />72 cs <br />NAME OF RESPONSIBLE PERSON: <br />I Am Not Required To Register As A Medical Waste Generator Because. <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, <br />incinerating or n-dcrowaving. <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 <br />generate or store any of the wastes specified on the Tre-Application Questionnaird" <br />as "Regulated Medical Wastes" in, a,n amount over 200 pounds per month. <br />I declare under penalty of law that I will not be treating any amount of "Regulated <br />Medical Wastes" at my facility by way of autoclaving, incinerating, or microwaving. <br />SIGNATURE: TITLE: 0LJAj_-eDATE: <br />�j <br />