Laserfiche WebLink
Certification Statement <br /> FOR NON-MEDICAL WASTE GENERA GENERATORS NOT REQUIRED TO REGISTER <br /> Business Name: <br /> Business Address: �/ �� !J�&IL�! C� ��� A <br /> C, rL 014- <br /> city State Zip Code <br /> Phone Number: (Q <br /> Contact Person: J/A!_!�Al A (7A_3/62E-i6�A <br /> I am not required to register as a Medical Waste Generator because: <br /> Please check the appropriate statements) <br /> 1✓ 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 or <br /> store any of the wastes specified on the "Pre-Application Questionnaire" as regulated medical <br /> wastes in an amount that equals or exceeds 200 pounds per month. <br /> Q I declare under penalty of law that I will not be treating any amount of regulated medical wastes <br /> at my facility by way of autoclaving, incinerating or microwaving. <br /> Signature: /J � � � Title: �/iCV/q- -�=Date: :zho <br /> EHD 45-03 3 <br /> 10/6/2003 <br />