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CERTIFICATION SrATFAIENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE, 'TORSI , F: <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) <br /> CT C 1 1991 <br /> BUSINESS NAME: , <br /> Pr S'L` F,',, <br /> BUSINESS ADDRESS: <br /> Street <br /> City State Zip <br /> PHONE NUMBER: <br /> NAME OF RESPONSIBLE PERSON: <br /> I Am Not Required To Register As Medical Waste for Because: <br /> [Please check the appropriate st ement(s).] <br /> I do not generate any edical waste. <br /> I generate less than 00 pounds of medical waste per month. <br /> I do not treat any'medical waste at my facility by means of autoclaving, <br /> incinerating ormicrowaving. <br /> j <br /> Other ' <br /> r <br /> I <br /> i <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 "Pre-Application Questionnaire" <br /> as`"Regulated Medical Wastes" in an amount over 200 pounds per month. <br /> f <br /> ( ) 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 /> SIGNATURE: TITLE: DATE: <br /> 5 <br />