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-Certification Statement x <br /> FOR N N-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT RE UIRED TO REGISTER <br /> Business Nam <br /> Business Address: <br /> \\,, <br /> City State Zip Code <br /> Phone Number: <br /> Contact Person: <br /> I am not required to register as a Medi 1 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 medic was per month. <br /> ❑ I do not treat any medical waste at my facili y means of autoclaving, incinerating or <br /> microwaving. <br /> ❑ Other: <br /> Please indicate the appropriate state nt(s): <br /> Ej I declare under penalty o aw that to the best of my knowled9 d belief, I do not generate or <br /> store any of the wastes pecified on the"Pre-Application Ques •onnaire" as regulated medical <br /> wastes in an amount at equals or exceeds 200.poundsper month: - <br /> ❑ I declare under pe alty of law that I will not be treating any amount o egulated medical wastes <br /> at my facility b ay of autoclaving, incinerating or microwaving. <br /> Signature: Title: Date: <br /> EHD 45-02-003 Page 3 of 7 <br /> 10/6/2003 <br />