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SA N._J 0 A Q U IN 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- e-A to <br /> Business Address: 1�z) <br /> City State Zip Code <br /> Phone Number: <br /> Contact Person: orAec Aa-- 'k - e_ n <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 month. <br /> F-1 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 /> XI declare under penalty of law that to the best of my knowledge and belief, I do not generate <br /> or store any of the wastes specified on .the <br /> the "Pre-Application Questionnaire" as regulated <br /> medical wastes in an amount that equals or exceeds 200 pounds per month. <br /> XI declare under penalty of law that I will not be treating any amount of regulated medical <br /> wastes at my facility by way of autoclaving, incinerating or microwaving. <br /> Signature. Y" Title:.. Date:c <br /> / 4 <br /> 4 of 11 <br /> --- <br />