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SANJ 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 <br /> REQUIRED TO REGISTER <br /> Business Name : dv'k�an BN + �'• � .-� Su � �,r•`)"� . `G <br /> Business Address : <br /> City State Zip Code <br /> Phone Number, <br /> Contact Person : �� a t�-'1 :> C11 <br /> 1 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 <br /> 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 <br /> store any of the wastes specified on the " Pre -Application Questionnaire " as regulated <br /> medical wastes in an amount 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 <br /> at my facility by way of autoclaving , incinerating or microwaving . <br /> Signature : Title : <br /> 4of11 <br />