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CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GE RATORS <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) / <br /> BUSINESS NA E: <br /> BUSINESS ADD SS: <br /> Street <br /> City State z`fZ' <br /> NAME OF RESPONS LE PERSON: <br /> PHONE NUMBER: <br /> I Am Not Required To Regi er As A Medical Waste Gen ator Because: <br /> [Please check the appropriate st ement(s).] <br /> I do not generate any medic waste. <br /> I generate less than 200 pound f medical ste per month. <br /> I do not treat any medical waste my fa `ity by means of autoclaving, incinerating or <br /> microwaving. <br /> Other <br /> Place an "X" next to the corres ding method facility uses to dispose of medical waste: <br /> _ Registered Medical Was Transporter (transporter name) <br /> _ Alternative Technol y Approved by DHS (treatment method) <br /> 1Inde enalty of law that to the best of my knowledge and bell Ido not generate or store any <br /> oeci led on the "Pre-Application Questionnaire" as "Reg ted Medical Wastes" in an <br /> a0 pounds per month. I also declare that I will not be treating ny amount of"Regulated <br /> "at myfacility by way of autoclaving, incinerating, or microw . g. <br /> TITLE: TE: <br /> (NOTE: IF YOU FILL OUT"CERTIFICATION"FORM DO NOT FILL OUT'REGISTRATION"FO ) <br /> 3 <br />