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p e ` <br /> CERTEnCATION SrATENENT <br /> FOR NON-MEDICAL GENERATORS MEDICAL WASTE GENERATORS <br /> NOT REQUIRED TO REGISTER <br /> (Please Type or Print) . _. .. <br /> BUSINESS NAME: EDISON HEALTH CENTER _ <br /> BUSINESS ADDRESS. <br /> Street 1425 South Center Street <br /> City Stockton, State CA Zip 95206 <br /> PHONE NUMBER: (209 ) 547-3990 <br /> NAME OF RESPONSIBLE PERSON: Sara Godwin, N.P. <br /> I Am Not ReqWred To Register As A Medical Waste Generator use: <br /> [Please check the appropriate statement(s).] <br /> I do not generate any medical waste. <br /> x 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 Stat (s): <br /> (x) 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 ed <br /> Medical Wastes"at my facility byway of autoclaving, inanerating,-or microwaving. <br /> SIGNATURE. AaJCLCOOck� PTTLE <br /> T :"�, DATE:'` "'/` <br /> 5 <br />