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CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL W SEP <br /> IRS <br /> ER <br /> NOT REQUIRED TO REGIST ` j ' <br /> vi/ <br /> (Please Type or Print) ~ <br /> BUSINESS NAME: Lo' <br /> -D i h-rz- AJy T AoA- (,,q Lep <br /> BUSINESS ADDRESS: <br /> Street YJ/ S 14-A1 L <br /> City � l7 / State Zip <br /> PHONE NUMBER: <br /> NAME OF RESPONSIBLE PERSON: 7ZL!�t S C- <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 /> I generate less than 200 pounds of medical waste per month. <br /> I do not treat any medical waste at my facility by means of autoclaving, <br /> incinerating or 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 <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 /> ( ) I 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 />