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CERTIFICAnON STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTEifR�IORS <br /> 4, <br /> NOT REQUIRED TO REGISTER `NVIROf PV�E N'T A L FH <br /> (Please Type or Print) P E R N;N T//S F.R V I C E S <br /> BUSINESS NAME: Akllooe Catnu lfuv.6.--r 40-SALtal <br /> BUSINESS ADDRESS: <br /> Street -=r/— <br /> city Zqggi I State zip <br /> PHONE NUMBER: 1 /cR cge? <br /> NAME OF RESPONSIBLE PERSON: <br /> I Am Not Required To Register As A Medical Waste Generator use: <br /> [Please check the appropriate statements)-1 <br /> I do not generate any medical waste. <br /> 1 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 /> (0j"- 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 n-dcrowaving. <br /> A -�XA <br /> SIGNATURE: AaW44,c DATE: <br /> 5 <br />