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SANJOAQUINEnvironmental Health Department <br /> COUNTY <br /> Certification Statement for Operators not required to Register <br /> Facility Name: T)IF YpW f--Jt GT IMEM C)R(A-L- Ch-ACCL <br /> Facility Address: to D #\I • C f::b RN IA 3r. <br /> City, State, Zip Code: s 10Ck--Tbt4 CA ct A57� � <br /> Phone Number: 0 • l'(pb <br /> Facility Contact and Title: i�CQI�I��--�� MOOPE 5EAY Ej'Yj %L, (nge-/r—b <br /> My facility is not required to register with the San Joaquin County Environmental Health Department <br /> because (check the appropriate statements): <br /> ❑ My facility does not generate regulated medical waste. <br /> ❑ My facility generates less than 200 pounds per month and does not treat regulated medical <br /> waste. <br /> ❑ My facility is not a common storage facility of regulated medical waste. <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are correct and true. <br /> Signature: <br /> Name and Title: r- Q <br /> Date: 0 v a / a'2 <br /> 2of11 <br />