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F <br /> Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: `lam�,A_ Tr6 })4 CT.( I n j <br /> � Business Address: <br /> I �, U�Gt l Pb: c a I rczC aS3`� <br /> YA <br /> cityi. State Zip Cade <br /> Phone Number: ( ) �?J� DSD <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 /> i <br /> Please indicate the appropriate statement(s): <br /> 4 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 /> Title: Date: <br /> Signature: <br /> �Y��ic � <br /> t - <br />{ <br /> 1 <br /> EHD 45-03 3 <br /> 10/6/2003 <br />