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a <br /> CERTIFICATION STATEMENT <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> BUSINESS NAME _k c <br /> BUSINESS ADDRESS <br /> Street fkk S U."'k t C) <br /> City Statelz Zip 9 ID 72 <br /> PHONE NUMBER 2-D 9 -- Zs*-z — <br /> CONTACT PERSON_ <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, incinerating, or <br /> 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 generate <br /> or store any of the wastes specified on the "Pre-Application Questionnaire" as regulated <br /> medical wastes in an amount that equals or exceeds 200 pounds per month. <br /> I declare under penalty of law that I will not be treating any amount of regulated medical <br /> wastes at my facility by way of autoclaving, incinerating, or microwaving. <br /> RN <br /> SIGNATURE TITLEa-ct ° e / DATEVWbL <br /> 3 <br />