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00 <br /> a6 g <br /> CERTIFICATION SrATEAENT <br /> FOR NON-MEDICAL 'E GENERATORS AND NEDICAL ° GENERATORS <br /> NOT REQUIRED TO GI - <br /> ( lease Type or t) <br /> BUSIN S NAME: <br /> BUSINESS S: <br /> Street <br /> city State Zip <br /> PHONE NUMBER: <br /> NAME OFRESPONSIBLE) : <br /> I Am Not o e Generato <br /> [Please check the appropriate stament(s).] <br /> I do not generate any medical�waste. <br /> I generate less than 200 pounds of medicalaste per month. <br /> I do not treat any medical waste atm ac' 'ty by means of autoclaving, <br /> incinerating or microwaving. <br /> Other <br /> Pl /ed <br /> Indicate • to Stat t(s): <br /> O enalty of law at to a best of my o ge belief, I do not <br /> any of the wastes specified on a App tion Questionnaire" <br /> " in an amount over 200 pounds per month. <br /> O enalty of law that I' not be trea ° y o t of" atet y facility by of autoclaving, incinerating, or microwaving. <br /> SIGNATURE: DATE: <br /> 5 <br />