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4 <br /> E to <br /> NOY 2 5 <br /> CERTIFICAnON STATEMENT T1.1 <br /> FOR NON-MEDICAL IV# <br /> NOT GI r,�v r �_. . <br /> AWRS <br /> (Please a or Print) <br /> BUSINESS E: PQJ L- L T L S-1y10u! <br /> BUSINESS SS: <br /> Street 16 C AF_ " i L r <br /> City ;:;i z2e-kv d State Zip a <br /> PHONE NUMBER: („,C ) V -7 -V 10 3 <br /> NAME OF RESPONSIBLE : r I S <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 medic . <br /> generate less than 200 pounds of medicalwaste per month. <br /> ✓` I do not treat any medical waste at my facility by means of autoclaving, <br /> incinerating or microwa ' g. <br /> Other <br /> Please indicate The Appropriate Statement(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' -Application estio " <br /> as "Regulated " in o t over 200 pounds per month. <br /> oz 1 declare under penalty of law that I will not be treating any amount of"Regulated <br /> Medical Wastes"at my facility by wayof autoclaving, incinerating, or microwaving. <br /> SIGNATU : r& /V,9 LJa, DATE:/, ®— / <br />