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SA N,J O A Q U I N Environmental Health Department <br /> --—C OU N-TY---- <br /> Certification <br /> rY----Certification Statement for Operators not required to Register <br /> Facility Name:kM It[ <br /> i <br /> Facility Address: <br /> i <br /> City, State, Zip Code: ?s+"e'T`1m J V" <br /> 011*7"0 <br /> Phone Number: LYIq` r"Ju�� <br /> Facility Contact and Title: k/VIVW ceuCy1 <br /> My facility is not required to register with the San Joaquin County Environmental Health Department <br /> because (check the appropriate statements): <br /> ❑ My facility does not generate regulated medical waste. <br /> l My facility generates less than 200 pounds per month and does not treat regulated medical <br /> waste. <br /> ❑ My facility is not a common storage facility of regulated medical waste. <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are correct and true. <br /> Signature: _. <br /> Name and Title: <br /> Date: <br /> 2of11 <br />