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CERTIFICATION STATEMENT <br /> F NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) <br /> BUSINES�.NAME: �IQ ' d �� /11 � � � ,�U G <br /> ti <br /> BUSINESS ADDRESS: <br /> Street Z <br /> City tJ G/j StateCg" Zip �S'2_ l 2,� <br /> PHONE NUMBER: ' <br /> NAME OF RESPONSIBLE P ON: <br /> I Am Not Required To Register As,A Medical aste Generator Because: <br /> (Please check the appropriate statement(s).JW <br /> I do not generate any medical wte. <br /> „ I generate less than 200 poui)ds of medical waste per month. <br /> — — Ido not treat any medicaaste atm 'un <br /> facility by means autocl v�f, <br /> incinerating or nucrowng. <br /> Other <br /> 'y `k <br /> Please Indicate T Appropriate Statement(s): <br /> ( ) I declare under penalty of law that to the best of my kno,�vledge and belief, I do not <br /> genote or store any of the wastes specified on the "Pre Application Questionnaire" <br /> as "tegulated Medical Wastes" in an amount over 200 pour ds per month. <br /> ( ) r declare under penalty of law that I will not be treating any amount of"Regulated <br /> Medical Wastes"at my facility by way of autoclaving, incinerating;''°or microwaving. <br /> 7.r' <br /> GNATURE: DATE: <br /> 5 <br />