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a. <br /> CERTIFICATION STATEMFIS& <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISIE <br /> (Please Type or Print) <br /> BUSINESS E: <br /> BUSINESSADDRESS: <br /> Street -/I- <br /> 4­25�f 9r- <br /> city State Zip 7 f <br /> PHONE NUMBER: ) a <br /> NAME F RESPONSII / ! <br /> I Am Not Required To Register As A Medical Waste Generator : <br /> (Please check the appropriate statement(s).] <br /> I do not generate any medical <br /> I generate less than 200 pounds of medicalwaste per month. <br /> I do not treat any medical waste at my facilitye of autoclaving, <br /> incinerating or microwaving. <br /> Other <br /> Please Indicate The Appropriate t <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 o the ' -Application Questionnaire!' <br /> as "Regulated " in o t 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 by way of autoclaving, incinerating, or microwaving. <br /> SIGNATURE: 1 1ma DATE: j <br />