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�71 <br />Certification Statement <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br />Business Name: �� • ��,5 �4Ck 1;{' I v' <br />Business Address: <br />Phone Number: <br />Contact Person: <br />City State Zip Code <br />I am not required to register as'a Medical Waste Generator because: <br />Please check the appropriate stateinent(s) /! <br />❑ I do not generate any medical waste. <br />❑ I generate less than 200 pound'No <br />f medical waste pe ponth. <br />❑ I do not treat any medical waste at`,my facility by,t�ieans of autoclaving, incinerating or <br />microwaving. l <br />❑ Other: <br />Please indicate the appropriate <br />❑ I declare under penalty of law that to the best of y knowledge and belief, I do not generate or <br />store any of the wastes specifj d on the "Pre -App 'cation Questionnaire" as regulated medical <br />wastes in an amount that eq} als or exceeds 200 r )uY4s per month. <br />Signature: <br />I declare under penalty oflaw that I will not be treatingamount of regulated medical wastes <br />at my facility by way of%autoclaving, incinerating or micro ving. <br />Title: Date: <br />EHD 45-03 3 <br />10/6/2003 <br />