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CERTIFICATION <br /> FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br /> BUSINESS NAME <br /> BUSINESS ADDRESS <br /> Street 081 M . OaAA <br /> Cit y state ,4zip <br /> PHONE NUMBER <br /> CONTACT PERSON — " <br /> • c r 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, 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 /> 1 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 /> SIGNATURE TITLE _ DATE 50 <br /> Ifit3 <br />