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E <br />E <br />OCT 2 <br />_1EALVH <br />)N <br />F ,xs <br />JSM <br />�AW <br />. TIU-STAW-44 <br />FOR NON-MEDICAL WASTE GENERATORS AM MEDICAL WASTE GENERATORS <br />NOT REQUIRED TO REGIST M - <br />(Please Type or Print) <br />BUSINESS NAME: <br />1- .11 �MMNME <br />CityState 6A ziv q&Qj � I <br />- j <br />PHONE NUMBER: (a0l'l ) 'aaH - 7?, A <br />NAME OF RESPONSIBLE PERSON: �- Gx-0 <br />I do not generate any medical waste. <br />generate less than 200 pounds of medical waste per month. <br />I do not tr eat any medical waste at my facility by means of autoclavig, <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 Tre-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 byway of autoclaving, incinerating, or microwaving. <br />SIGNATURE: <br />j,4-o3rDATE: 10/1 <br />5 <br />