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Certification Statement <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br />Business Name:J3A D1 ) l <br />Business Address: f <br />L � <br />City State Zip Code <br />Phone Number: <br />Contact Person: 1WW <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, 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 />❑ I declare under 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: Title: Date: <br />EHD 45-03 3 <br />10/6/2003 <br />