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� ( ( ( t11 Environmental Health Department <br /> SAN JOAOC O U N T Y __. ._1.1 <br /> ( Certification Statement for Operators not required to Register <br /> Facility Name : <br /> Facility Address : <br /> City , State , Zip Code : <br /> Phone Number : <br /> Facility Contact and Title : <br /> My facility is not required to register with the San Joaquin County Environmental Health Department <br /> because ( check the appropriate statements ) : <br /> F1My facility does not generate regulated medical waste . <br /> My facility generates less than 200 pounds per month and does not treat regulated medical <br /> waste . <br /> My facility is not a common storage facility of regulated medical waste , <br /> I <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are correct and true . <br /> Signature : <br /> i <br /> Name and Title : <br /> ( Date : <br /> Version : 8-3-23 Page 2 of 1 .1 <br />