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CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) <br /> BUSINESS NAME: _ (�Q_�-_;o Cry R E <br /> BUSINESS ADDRESS: <br /> Street tiolkD E 8rarcau. &,Gec A-1 <br /> City g+0 n State —CA Zip as <br /> NAME OF RESPONSIBLE PERSON: Trr s o Q4►weft <b. Ghr sA-,-ne. Maek-m <br /> PHONE NUMBER: (Pok )._ 412,- oti 8 4 <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 /> Place an "X" next to the corresponding method your facility uses to dispose of medical waste: <br /> X Registered Medical Waste Transporter S--er: Gly. inc- . (transporter name) <br /> Alternative Technology Approved by DHS (treatment method) <br /> I declare under penalty of law that to the best of my knowledge and belief, I do not generate or store any <br /> of the wastes specified on the "Pre-Application Questionnaire" as "Regulated Medical Wastes" in an <br /> amount over 200 pounds per month. I also declare 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: -g� <br /> (NOTE: IF YOU FILL OUT "CERTIFICATION" FORM DO NOT FILL OUT "REGISTRATION" FORM ) <br /> 3 <br />