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T Jan.31, 2012 10:32AM 6D MEDICAL ENGINEERING No,5494 P. 4 <br />Certification Statement <br />FOR NON-MEDICAL WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT .. OUIRED TO REGISTER <br />Business Name: <br />Business Address: <br />City state Zip Code <br />Phone Number: <br />Contact Person: <br />I am not required to register as a Medical Waste Generator because: <br />,Please check the appropriate starement(s) <br />❑ I do not generate any medical waste. <br />❑ I generate less than 200 pounds of medical waste per month. <br />❑ 1 do not treat any medical waste at my facility by means of autoclaving, incinerating or <br />microwaving. <br />❑ Other: <br />Please indicate the appropriate stntement(s): <br />❑ 1 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 />Signature <br />It <br />EHD 45-03 <br />10/6/2003 <br />1 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 />0 <br />It <br />