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x <br /> CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br /> T REQUIRED TO REGISTER <br /> (Pl s r <br /> r c A � n;+r <br /> BUSINESS N : me ttTkt w (o,4 <br /> BUSINESS SS: i S Yl ame <br /> Street 5131 L, <br /> city <j2Ck tzY1r1 State CA Zip l 4 <br /> PHONE NUMBER: ( ) <br /> NAME OF RESPONSIBLE PERSON: � <br /> I Am Not Requiried To Register As A Medical Waste Generator ° <br /> [Please check the appropriate statement(s).] <br /> I do not generate any medical waste. <br /> I generate less than 200 pounds of medicalwaste per month. <br /> I do not treat any medical waste at my facility by means of autoclaving, <br /> incinerating or microwa ° g. <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 ' -Application Questionnaire" <br /> as at " in o t over 200 pounds per month. <br /> ( ) I declare under penalty of law that I will not be treating any amount of"Regulated <br /> Medical Wates"at my facility byway of autoclaving, incinerating, or microwaving. <br /> SIGNATURE: ) ATE: I � <br />