Laserfiche WebLink
CER CATION STATEINMNiT <br /> FOR N -MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) <br /> BUSINESS NAIL: <br /> BUSINESS ADDRESS. <br /> Street <br /> City State _ Zip <br /> NAME OF RESPONSIBLE RSON: <br /> PHONE NUMBER: ( ) <br /> Y Am Not Required To Register: A Medical Waste Generator Because: <br /> [Please check the appropriate statem t(s).] <br /> I do not generate any medical w <br /> I generate less than 200 pounds o waste per month. <br /> I do not treat any medical waste atm f by means of autoclaving, incinerating or <br /> microwaving. <br /> Other <br /> Place an "X" next to the corresponding method your cility uses to dispose of medical waste: <br /> Registered Medical Waste Transporter (transporter name) <br /> Alternative Technology Approved by DHS (treatment method) <br /> I declare under penalty of law that to the best of my knowledge and belie I do not generate or store any <br /> of the wastes specified on the "Pre Application Questionnaire`° as "Reg ated Afedical Wastes" in an <br /> amount over 200 pounds per month I also declare that I will not be treatin any amount of"Reg ulated <br /> iWedical Wastes"at my facility by way of autoclaving, incinerating or microw ing. <br /> SIGNATURE: TITLE: DATE: <br /> (NOTE: IF YOU FILL OUT"CERTIFICATION"FORM DO NOT FILL OUT"REGISTRATIO "FORAM) <br /> 3 <br />