Laserfiche WebLink
Certification Statement <br />FOR NON-MEDICAL WASTE GENE, _RATORS AND MEDICAL WASTE GENERATORS <br />Business Name: <br />Business Address: <br />City State Zip Code <br />Phone Number: <br />Contact Person: <br />I am not required to register as a Medical Waste Generator because: <br />Please check the qj)j_?roj.,n1a1e Statement(s) <br />E] I do not generate any medical waste. <br />F] I generate less than 200 pounds of medical waste per month. <br />F1 I do not treat any medical waste at, my Eacility by means of atitoclaving, incinerating or <br />rnicrowaving, <br />EJ Other: <br />F-1 I declare under penalty of law that to the best of my knowledge and belief, 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 waste's <br />at my facility by way of autoclaving, incinerating or microwaving. <br />Signature: Title: Date: <br />F 111) 45-03 <br />