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Certification Statement <br /> FOR NON- AND MEDICAL WASTE GENERATORS NOT 1�E UZz2ED r0 REGISI7ER <br /> Business Name: <br /> Business Address: <br /> City State ,Zip Code <br /> Phone Number: ( ) <br /> Contact Person: <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 mouth. <br /> ❑ I do not treat any medical waste at my facility by means of autoclaving, incinerating or <br /> rnicrowaving. <br /> ❑ Other: <br /> JPlease 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 medical <br /> 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: bate: <br /> 1=HD 45,03 3 <br /> 10/b/2003 <br /> 000 'd 'ON M NV 21 : 11 I1HI/6102/IUEHd <br />