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® 1 <br /> CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) <br /> BUSINESS NAME: <br /> BUSINESS ADDRESS: <br /> Street <br /> City State Zip <br /> NAME OF RESPONSIBLE PERSON: <br /> PHONE NUMBER: ( ) <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 /> Igenerate 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 <br /> microwaving. <br /> Other <br /> Place an "X" nest to the corresponding method your facility uses to dispose of medical waste: <br /> — Registered Medical Waste Transporter (transporter name) <br /> — Alternative Technology Approved by DHS (treatment method) <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 <br /> amount over 200 pounds per month. I also declare that I will not be treating any amount of"Regulated <br /> Medical Wastes"at my facility by way of autoclaving, incinerating, or microwaving. <br /> SIGNATURE: TITLE: DATE: <br /> (NOTE: IF YOU FILL OUT"CERTIFICATION" FORM DO NOT FILL OUT"REGISTRATION"FORM) <br /> 3 <br />