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SANJOAQUIN Environmental Health Department <br /> _—C O U N T Y------- <br /> Certification <br /> -_____Certification Statement <br /> FOR NON-MEDICAL_ WASTE GENERATORS AND MEDICAL WASTE GENERATORS NOT <br /> REQUIRED TO REGISTER <br /> Business Name: wvi "E <br /> Business Address: 699 <br /> = M <br /> City State Zip Code <br /> Phone Number: ) 41 -71- 4s(12 <br /> Contact Person: I <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 /> Af <br /> Signature: . Title: Date: `f f I U 2074) <br /> 4of11 <br />