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10/12/2022 10:35 FAX IM0003/0006 <br /> SA N J O 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: Grant Line Dialysis <br /> Business Address: 2955 N Corrall Hollow Rd Ste 101 <br /> Tracy CA 95376-8800 <br /> City State Zip Code <br /> Phone Number: ( 209 ) 839-8302 <br /> Contact Person: Courtney Vela <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 /> Courtney Vela Digitally signed by cnurtney Vela <br /> D,,,2020.07.2012.1842 0700' +� <br /> Signature: Title: FG�(;i j)�4 Admtnisfrc�b✓ Date: <br /> 3 of 8 <br />