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0902712013 07:48 20946551.2B CLC PORT BO PAGE 04'04 <br /> Certification Statement a <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: CeWe., L.UUIR41 Cr6*ee ParArl e <br /> Business Address: ZTio N. C A 1-!f aR N A 34. <br /> S4a---L4n c® gr s'z 0-4 <br /> city State Zip Code <br /> Phone Number: (20- )*"-35-ZZ <br /> Contact Person: �,�,a �_ r.t a jv- <br /> I am not required to register as a Medical Waste Generator because: <br /> Please check the appropriate statements) <br /> ❑ I do not generate any medical waste. <br /> I generate less than ZOO hounds of medical waste per month. <br /> [� I do not treat any medical waste at my facility by means of autoclaving,incinerating or <br /> uXucrowaving. <br /> ❑ <br /> Other: <br /> Please indicate the appropriate statement($): <br /> `Q 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"Pro-Application Questionnaire"as regulated medical <br /> wastes in an amount that equals or exceeds 200 pounds per month. <br /> ( 1 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: C'-AreorAlf PsAferat Dat : 244 SEP13 <br /> EHDD 45-03 3 <br /> 1ar6/"03 <br />