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rte, <br />FOR NON-MEDICAL WASTE GENERATORS AND IMEDICAL WASTE GENERATORS NOT REQUIRED TO REGISTER <br />Business Name: <br />Business Address: <br />Phone Number: <br />Contact Person: <br />city State Zip .. <br />L_X_q 1 1-9 9k <br />J) 111�, kw ?V�M11,1W - �AvA <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 statements): <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 />IP I declare under r <br />at my facility by <br />Signature: <br />EHD 45-03 <br />2015 <br />of law that I will not be treating any amount of regulated medical wastes <br />E autoclaving, incinerating or microwaving. <br />9 <br />M <br />