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<br />3 of 8 <br /> <br />Environmental Health Department <br />Certification Statement <br /> <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED <br />TO REGISTER <br /> <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br /> <br /> City State Zip Code <br /> <br />Phone Number: ( ) <br /> <br />Contact Person: <br /> <br /> <br />I am not required to register as a Medical Waste Generator because: <br /> <br />Please check the appropriate statement(s) <br /> <br /> I do not generate any medical waste. <br /> <br /> 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 microwaving. <br /> <br /> Other: <br /> <br /> <br />Please indicate the appropriate statement(s): <br /> <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 amount <br />that equals or exceeds 200 pounds per month. <br /> <br /> I declare under penalty of law that I will not be treating any amount of regulated medical wastes at my <br />facility by way of autoclaving, incinerating or microwaving. <br /> <br /> <br />Signature: Title: ________________________ Date: ______ <br /> <br /> <br /> <br /> <br /> <br />