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Received: Sep 2 2011 10:14am <br /> 09/02/2011 10:01 2098589G"@ PREFERRED ALLIANJ& PAGE 02/04 <br /> 19 <br /> Certification Statement <br /> FOR NON- IDICAL WASTg_q&NFB&TOR Alun MEDICAL WASTE GIENIERATORS NQjAgQjDMgp T9 1,z <br /> 2AN gjSTk:3t <br /> Business Name: <br /> Business Address- Z49 <br /> 42 <br /> Cm <br /> State Zip Cndc <br /> Phonc Number: <br /> Contact Person, <br /> I am not required to register as a Medical Waste Generator because: <br /> Please check rhe appropriate statements) <br /> 1:1 1 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 /> F-I 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 /> 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:.. Date: <br /> V <br /> 1016/2003 3 <br />