Laserfiche WebLink
V11111 <br /> CERTIFICATION <br /> FOR N- I TO I <br /> NOT REQUIRED TO G , �,t � S . �-. S <br /> (Please Type or Print) <br /> - <br /> BUSINESS NAME.- \40WI <br /> BUSINESSADDRESS: <br /> Street <br /> City State Zip <br /> PHONE NUMBER: <br /> NAME OF RESPONSIBLE <br /> I Am Not Required To Register As Medical Waste Generator : <br /> [Please check the appropriate state ent(s).] <br /> I do not generate any medical ste. <br /> I generate less than 200 pounds o medical waste per month. <br /> „ I do not treat any medical waste at y facility by meansof autoclaving, <br /> incinerating or microwaving. <br /> Other <br /> Please Indicate The Appropriate Statement(s): <br /> O I declare under penalty of law`that to the best omy owlege and belief, I do not <br /> generate or store any of the wastes specified on e' - tion estio " <br /> as t " in an o t ov 200 pounds per month. <br /> ( ) I declare under penalty of law that I will not be treat* gany o t of" ted <br /> e ' t "at y facility byway of atocla ' g, cinerating, or microwa ' g. <br /> SIGNATURE: : <br /> 5 <br />