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09/07/99 22:47 Z 209 9574142 TRIGUERO P.04 <br /> 8-25-1999 12: 1 1 Pf I Mot i <br /> CERTITICATIO14 "I ATE, <br /> pop,NON-MEDICAL WAS-f F (j-r--'NEv.,A'j,0rtS j\3NIUMCAL WASTE G MIRATORS <br /> NOUTRED IT.) REGISTER <br /> (Please Type or Print) <br /> CAI(?, <br /> ])US MESS NAME: -1—.,- .. I I -I-A/ <br /> BUSMSS ADDMSS: V <br /> Street t 4 <br /> city— :5=01 tate - <br /> N, AIML- Of RE SPONSIBLE PERSON- <br /> PHON-F NUNMER: <br /> I Am Not Required To Repter As A Medical Waste Generator Because; <br /> [Please check the appro priatestatement(s).] <br /> I do not generate any uxedical waste. <br /> I gCj]eMtC less '400 pound` of ruedicaJ waste per 4wildl. <br /> I do aot treat ally -mcdiral w at my facility by uAtans of aumlaving, ineineraring,or <br /> aticrowaving. <br /> Other.. <br /> (40) <br /> Place an "X" next to the corresponding method your facWtv uses to dispose <br /> 9- <br /> , . tz, - <br /> C4 5; <br /> z <br /> oxer name) <br /> Registered Nlcdical Waste Trmspor%er --1 <br /> 7 A!wn <br /> Altemative Technology Approved by DHS ,—(treatwem method) <br /> I declare under penalty of low that to the best of my knowledge and belief, I do not gvnerare or store any <br /> of the wastes specified on the 17.,&,4pplicafina Quevionnaire" as "Regulated Medical Wares" in an <br /> amount over 200 pounds per rnon(h I alto declare t I will not be treating any amount of"Reg,ulated <br /> Afgdlcal Wastes"at nVfaciUry by way of autoclaving, incineraring, or microwaving. <br /> TLE: h _L -A(19ATE.0-21CL� <br /> mi Lf <br /> SJGNATU�- 7- <br /> (NOTE; IF YO 'f OOT"C'ERTIMCATION"FORM Do NOT FILL OUT WOSTRATION"FOILM <br /> 3 <br />