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4 , 4 <br /> 0 <br /> 0 <br /> CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENE RATORS AND MEDICAL ' GENERATORS <br /> T REQUIRED TO REGISTER <br /> (Please Type or t) <br /> BUSINESS : <br /> BUSINESSADDRESS: <br /> Street <br /> City State Zip <br /> PHONE BER: <br /> NAME F RESPONSIBLE PERSON: <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 waste. <br /> I generate less than 200 pounds of medicalto per month. <br /> I do not treat any medical waste at my facility by means of autoclaving, <br /> incinerating or n-dcrowaving. <br /> Other <br /> Please Indicate The Appropriate Statement(s): <br /> O 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 Tre-Application Questionnaire" <br /> as "Regulated e i " in o t 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 Wat "at my facility byway of autoclaving, incinerating, or microaving. <br /> SIGNATURE: TITLE: <br />