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Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: <br /> Business Address: <br /> City State Zip Code <br /> Phone Number: ( C ) ':f 3 <br /> C)C24- <br /> Contact Person: A-T(—): / rz_-T'_ C�.V <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: Date: I <br /> EHD 45-03 3 <br /> 10/6/2003 <br />