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Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: Av `fes _ ® -t-�N ° der k�✓ <br /> Business Address: 0,57-2--, 2 . Mr,?-LK Lw,jCz --B 20 <br /> City State Zip Code <br /> Phone Number: ( acj 0 0 <br /> Contact Person: <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: 4A112 Title: F. i'l Ad-,-4 Date: <br /> EHD 45-03 3 <br /> 10/6/2003 <br />