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0 T 3 1 <br />-A' TH <br />E V li R0 ", I E N T.;')t i V-`� - L <br />CERTIFICATION STATEMENT )�zn W <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE- &Nikk <br />NOT REQUIRED TO REGISTE R <br />(Please Type or Print) <br />BUSINESS NAME: <br />BUSINESS ADDRESS: <br />Street <br />CiState Zip <br />ty V, <br />PHONE NUMBER: c <br />NAME OF RESPONSIBLE PERSON: IV( <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, <br />incinerating or microwaving. <br />Other <br />1-0MI73-TITOT W.171rju!)INJO) <br />1 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 'T�re-Application Questionnaire!' <br />as "Regulated Medical WastW 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 rnicrowavmig. <br />SIGNATURE�.:-:L, mTITLE: DATE: /a 1-2- V A <br />0 <br />