Laserfiche WebLink
CERTEFICATION STATEMENT <br /> FOR NON-MIEDICAL WASTE GENE RATORS AND MEDICALGENERATORS <br /> T REQUIRED TO REGISTER <br /> (Please Type or t) <br /> BUSINESS E: <br /> BUSINESSADDRESS: <br /> Street <br /> city State Zip <br /> PHONE NUMBER: <br /> NAME OF RESPONSIBLEPERSON: <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 200pounds of medical waste per month. <br /> I do not treat any medical waste at my facility by means of autoclaving, <br /> incinerating or microwaving. <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 "Pre-Application Questionnaire <br /> as at " 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 t "at my facility byway of autoclaving, incinerating, or microwaving. <br /> SIGNATURE: DATE: <br /> 5 <br />