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APR-06-11 10:34 FROM- 0 0 T-853 P.06/13 F-873 <br /> Certification Statement <br /> FUR MN MEnTC�AL WASTE GENERATORS AND MEDICAL WASTE GEA'ERATORS NOT Mgt)(RED TO REGISTER <br /> Business Name: <br /> POW www <br /> Business Address: S <br /> City Sate Zip Code <br /> Phone Number: (_o7o 9) 9.:52t 2 <br /> Contact Person: �L /5��� <br /> I am not required to register as a Medical Waste Generator becau : <br /> please check rhe app riare sraremenl(s) / <br /> ❑ I do not gene r any medical waste. <br /> (] 1 generate less than 0 pounds of medical wast per month. <br /> FI I do not treat any medical rite at my facili by means of autoclaving,incinerating or <br /> microwaving. <br /> [] Other: <br /> Please indicate the appropriate state ent(s): <br /> [] I declare under penalty o law that to the st of my knowledge and belief,I do not generate or <br /> store any of the wastes pecified on the"Pr Application Questionnaire" as regulated medical <br /> wastes in an amount at equals or exceeds 2 pounds per month. <br /> I declare under pen ty of law that 1 will not be trea 'ng any amount of regulated medical wastes <br /> at my facility by y of autoclaving,incinerating or 'crowaving. <br /> Signature: Tit]e_ Date- <br /> EkID 45-03 3 <br /> 10/6(2003 <br />