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Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: --iYO . ()VU <br /> Business Address: 3n o 5, r,,A cL.cA v <br /> City State Zip Code <br /> f Phone Number: ( ad Cl <br /> Contact Person: jan <br /> I am not required to register as a Medical Waste Generator because: <br /> Please check the appropriate statement(s) <br /> 'Er'f do not generate any medical waste. <br /> j ❑ I generate less than 200 pounds of medical waste per month. . <br /> { <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: [ 4 Title: Y�+ Date: l� <br /> EHD 45-03 .3 <br /> 1016!2003 <br /> I <br />