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SEP 12 1991 <br /> =u V 1 C ?l\P rIt_ l€AIL 1-1 ENL H <br /> CERTIFICATION STATEhlt a I s 3 /S",`w'i c'V# IES) <br /> FOR NON-MEDICAL ATMEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO I M- <br /> (Please Type or t) <br /> BUSINESS NAME: Le- La' i) /,kj LF a.,L� <br /> BUSINESS ADDRESS: <br /> Street <br /> City c o State Zip <br /> PHONE BER: CS_2 <br /> NAME OF RESPONSIBLE PERSON: �� 2 <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 medicalwaste. <br /> Ig enerate less than 200 pounds of medic" <br /> a 'c waste onth. <br /> I do not treat y medical waste at my facility by meansof autoclaving, <br /> incinerating or microwaving. <br /> Other <br /> Please indicate The Appropriate Statement(s): <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 "Resulated 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 ast "at my facility byway of autoclaving, incinerating, or microwaving. <br /> SIGNA 2 <br /> : <br />