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CERTIFICATION STATEMENT <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br />NOT REQUIRED TO REGISTER <br />(Please Type • Print) <br />BUSINESS NAME: <br />Street <br />Em <br />PHONE NUMBER: ( <br />NAME • .• PERSON. - <br />State zip <br />I Am Not Required To Register As A Medical Waste Generator Because: <br />(Please check the appropriate sitatement(s).] <br />I do not generate any medical waste. <br />I generate less than 200 pounds of medical waste per month. <br />I <br />•• • treat any medical wa• means • autoclaving, <br />incinerating • • <br />Other <br />Please Swtwienj[jj <br />I 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 Questionnaire <br />as "Regulated Medical, WastW in an amount over 200 pounds per month. <br />O 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 />�j <br />