Laserfiche WebLink
Certification Statement <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL <br /> tWASTE GENERATORS/NOT REOMED TO REGISTER <br /> Business Name: S-�• u ®S t M Y►'f��`�1 1. �� <br /> Business Address: r l ry 4 i D <br /> S`i�Gtc.�yrt �- r1SZ l � <br /> CityState Zip Code <br /> //�� <br /> Phone Number: ( gVb `"C� I _ � <br /> Contact Person: <br /> I am not required to register as a Medical Waste Generator because: <br /> Please check the appropriate statements) <br /> ❑ I do not generate any medical waste. <br /> ❑ I generate less than 200 pounds of medical waste per month. <br /> do not treat any medical waste at my facility by means of autoclaving,incinerating or <br /> microwaving. <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 generate or <br /> store any of the wastes specified on the"Pre-Application Questionnaire"as regulated medical <br /> wastes in an amount that equals or exceeds 200 pounds per month. <br /> [�I declare under penalty of law that I will not be treating any amount of regulated medical wastes <br /> at my facility by way of a claving,incinerating or microwaving. <br /> Signatures Title: ^��y Date: <br /> EHD 45-03 3 <br /> 10/6/2003 <br />