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CERTIFICATION STATEM <br />• ' NON-MEDICAL WASTE GENERATORS / MEDICAL WASTE GENERATORS <br />NOT REQUIRED • REGISTER <br />•. • Print) <br />BUSINESS NAME: <br />city State zip <br />PHONE NUMBER: C <br />NAME OF RESPONSIBLE PERSON: <br />ii • ' . i G i f• Aegister i G1 G • i <br />(Pleasei • i <br />I do not generate any medical waste. <br />I generate less than 200 pounds of medical waste per month. <br />•. • not i by ofautoclavmig, <br />incinerating • Smicrowaving. <br />Please Indicate The Appropriate Statement(s): <br />-1 declare under penalty of law that to the best of my knowledge and belief, I do not <br />generate or store any of the wastes specified on the "Pre -Application Ques <br />as • . es" in an amount over 200 pounds per month. <br />declare underpenalty •law that I will not1'treating <br />.- . 'any amountof "Regulated <br />• : bywayofautoclaving,incinerating, or i <br />SIGNATURE: <br />DATE: <br />