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Ll <br />r <br />FOR NON-MEDICAL WASTE GENE RATORS AND MEDICALGENERATORS <br />NOT REQUIRED TO REGISTER <br />(Please Type or Print) <br />BUSINESS NAME: <br />BUSINESSADDRESS: <br />Street <br />City State Zip <br />' i ' = <br />NAME OF RESPONSIBLE PERSON: <br />I Ain Not ReqWred '.. • Register Medical a Generator <br />(Please appropriate <br />I do not generate any medical waste. <br />I generate less than 200 pounds of medical waste per month. <br />•# I not •icat waste at my facility by means of autoclaving, <br />incinerating #r n-dcrowaving. <br />Other <br />C04ease Indicate The Appropriate Staternent(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 Tre-Application QuestionmiW <br />as "Regulated Medical Wast& 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 Wastes" at my facility by way of autoclaving, incinerating, or microwaving. <br />SIGNATURE: DATE: <br />9 <br />