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5 <br /> Ot/10/2011 11:22 x![}.176 D03 <br /> Certification Statement <br /> FOR NON-M):DICAIL wASTR GrNF tATQKS AND MEDICAL WASTE GENERATORS NOT REQUIRE Q IQ REGISTER <br /> Business Dame: Pw,r J 9 /C 4,15tfe <br /> Business Address: <br /> CA <br /> City State Zip Code <br /> Phone Number: f <br /> Contact Person: -r <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 f <br /> microwaving. <br /> ❑ other: <br /> i <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 <br /> store any of the wastes specified on the`Pro-Application Questionnaire" as regulated medical <br /> wastes in an amount that:equals or exceeds 200 pounds per mouth. <br /> ❑ I declare under penalty of law that I will not be treating any amount:of regulated medical wastes j <br /> at my facility by way of autoclaving, incinerating or microwaving, F <br /> Signature: Title: `+ Date: �• <br /> �7rt't� ►�''S �. <br /> I <br /> 12110 0-63 3 ' <br /> 1flMDA3 i <br />