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SA N J U A Q U I N Environmental Health Department <br /> COUNTY <br /> Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED <br /> TO REGISTER <br /> Business Name: <br /> Business Address: <br /> City State Zip Code <br /> Phone Number: ( ) <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 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 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 /> ❑ 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 /> Signature: Title: Date: <br /> 3 of 8 <br />