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E:5 <br /> � r�NM�P�TAL HEALTH <br /> CERTIFICATION ST�� �I "C, <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) <br /> BUSINESS NAME: Cflolz <br /> BUSINESS ADDRESS: <br /> Street ill-Q, <br /> City Lo S1 7 State Zip z <br /> PHONE NUMBER: 00 ) LX— 7) 1-1 <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 /> 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 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 <br /> generate or store any of the wastes specified on the "Pre-Application Questionnaire" <br /> as "Regulated Medical Wastes" in an 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 /> SIGNATU TITLE: �6_' ATE: <br /> 5 <br />