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0 0 <br />Certification Statement <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br />Business Name: S�'. �0 `S r <br />Business Address: ' b 1400 <br />Sfo Crib - <br />City State Zip Code <br />Phone Number: ) (P f <br />Contact Person: ��hn Kms► <br />I am not required to register as a Medical Waste Generator because: <br />Please check the appropriate statement(s) <br />❑ I do not generate any medical waste. <br />❑ Ige ate less than 200 pounds of medical waste per month. <br />I do not treat any medical waste at my facility by means of autoclaving, incinerating or <br />microwavmg. <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 />declare under penalty ow that I will not be treating any amount of regulated medical wastes <br />at my facility_by way opotoclaving, incinerating or microwaving. <br />Signature <br />EHD 45-03 <br />10/6/2003 <br />