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CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> BUSINESS NAME <br /> BUSINESS ADDRESS <br /> Street <br /> City State —Zip_ <br /> PHONE NUMBER <br /> CONTACT PERSON <br /> I am not required to register as a Medical Waste Ge erator because: <br /> [Please check the appropriate statement(s)] <br /> I do not generate any medical waste <br /> I generate less than 200 pounds of medi I waste per month <br /> I do not treat any medical waste at m facility by means of autoclaving, incinerating, or <br /> microwaving <br /> Other <br /> Please indicate the approp iate statement(s): <br /> 0 1 declare under 1) alty of law that to the best of my knowledge and belief, I do not generate <br /> or store any of he wastes specified on the "Pre-Application Questionnaire" as regulated <br /> medical waste in an amount that equals or exceeds 200 pounds per month. <br /> ❑ I declare der penalty of law that I will not be treating any amount of regulated medical <br /> wastes a my facility by way of autoclaving, incinerating, or microwaving. <br /> S NATURE TITLE DATE <br /> 3 <br />