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Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: rexncl ?41A ji A <br /> EDr <br /> 0 C. do <br /> '' ii C <br /> Business Address: �, "1�f�j� <br /> L.�D� �r - �- <br /> City State Zip Code <br /> Phone Number: ( 1 1� -s 7�ZZ <br /> -- <br /> Contact <br /> Contact Person: e- C /I' <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, 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: �_ ate: t' <br /> IF IF <br /> EHD 45-03 3 <br /> 10/6/2003 <br />