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Certification Statement <br /> )FOR NNQ1S--MDICAL'WASTE GENERATORS AND MEDICAL WASTE GENERATORS LW REO1aPJE1D TO REGISTER <br /> Business Name: �Po�-s <br /> Business Address: <br /> City State Zip Code <br /> Phone Number: <br /> Contact Person: b <br /> 1 am not required to register as a Medical Waste Generator because: <br /> Please check the appropriate statements) <br /> El 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, incinerating or <br /> microwaVing. <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 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 /> rn <br /> q,L I declare un0er penalty of law that I will not be treating any amount of regulated medical wastes <br /> at my facility by way of autoclaving, incinerating or microwaving, <br /> Signature: P�Date: a�0-6 �fe-, <br /> EHD 45-03 <br /> 60 [/Sl 'd zS� � "N MS : 6 �H '0[ 'IdV <br />