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0 <br /> CERTIFICATION STATEN ENT` <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL W - GENERATORS <br /> NOT REQUIRED TO REGISTMR <br /> (Please Type or Print) - <br /> BUSINESS NAME: / W <br /> 0 CT 0 1 iqqi <br /> BUSINESS ADDRESS: / <br /> �F <br /> Fr $ <br /> Street u_..i•.,Va i .Ts.._. _ K.... <br /> City r` State Zip <br /> l <br /> PHONE NUMBER: S ) <br /> NAME OF RESPONSIBLE PERSON: <br /> I Am Not Required To Register As A Medical Waste Generator Because: <br /> [Please check the appropriate statement(s).] <br /> l <br /> I do not generate anynmedical waste. <br /> I generate less than`200 pounds of medical waste per month. <br /> I do not treat *Y medical waste at my facility by means of autoclaving, <br /> incinerating ox` nrucrowaving. <br /> I <br /> Other <br /> f <br /> f <br /> i <br /> l` <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 <br /> generate or store any of the wastes specified on the "Pre Application Questionnaire" <br /> as "Regulated Medical Wastes" in an amount over 200 pounds per month. <br /> ( ) I declare under penalty of law that I will not be treating any amount of"Regulated <br /> Medical Wastes"at my facility by way of autoclaving, incinerating, or microwaving. <br /> SIGNATURE: TITLE: DATE: <br /> 5 <br />