Laserfiche WebLink
OCT <br /> _H <br /> F Vi <br /> CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENE RATORS AND MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISTE R <br /> (Please TWe or Print) <br /> BUSINESS NAME: <br /> I v' nic� <br /> BUSINESS ADDRESS: <br /> Street Vf)LRLvj <br /> city State",,,. C-A zip <br /> PHONE NUMBER: LV OR � <br /> A I jn bLo <br /> NAME OF RESPONSIBLE PERSON: <br /> I Am Not Required To Register As A Medical e Generator Because: <br /> [Please check the appropriate statement(s) <br /> A M dical <br /> 0 <br /> ast <br /> itemen�(s) <br /> Ij w/ <br /> I do not generate any medical ste. <br /> I generate less than 200 po ds of medical waste per month. <br /> I do not treat any medic to at my facility by means of autoclaving, <br /> incinerating or micro ving. <br /> Other <br /> PleaseIndica/tee Appropriate Statement(s): <br /> O 1 <br /> I decl e 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 Questionnaire!' <br /> as "Regulated Medical Wastes" in an amount over 200 pounds per month. <br /> I declare under penalty of law that I will not be treating any amount of"Regulated <br /> Medical Wastes"at my facility byway of autoclaving, incinerating, or n-dcrowaving. <br /> SIGNATURE: TITLE: DATE: <br /> 5 <br />