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r.ipi-en <br />ENVIRONMENTAL SIERlncri- <br />San Joaquin Co. 1-1114 <br />7850 South R.A. Bridgeford St CE -SQG DATA 'TEE T & WAIVER <br />Stockton, CA 95206 <br />Telephone (209) 468-5670 <br />Fax:(209) 468-5672 <br />RIE0 D <br />, E 11Y E D <br />APR 2 8 (2010 <br />ENVIRCWEq" HEAJH <br />JOB#. 6J28206P IT/SERVI CES <br />SA000046 <br />Company Name A Street Sirnog & Test only Cent Com an Re r�sentafi:e <br />ISueet Address: 109 S A Street E-mail: <br />kity/statelZip Code; Stockton Ca 95203 rea code 3 relep one #: <br />Area Code d Fax NumDer <br />8uatneae Waiver <br />State and federal hazardous waste laws limit the use of this type of waste collection programs to those businesses that <br />generate less than 100 kilgrams (27 gallons or 220 pounds) of hazardous waste per month. Businesses that generate more <br />than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport their waste. Therefore, <br />in order to participate in this program, you must sign the following wasiver of liability. Vlie reserve the right to review your annual <br />manifests or consult with the County Environmental Health Department to determine your eligibili <br />Thank you, ty for use of this Program, <br />I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator (CESQG) who generates no <br />more than 100 kilograms (27 gallons or 220 pounds) of hazardous waste per month based on an annual average and 1, the <br />representative of the CESQG, understard the maximum quantity of waste accepted at the time for disposal is 27 gallons or 220 <br />pounds and any disposal costs incurred shall be the responsibility of the CESQG to pay at the time of disposal. <br />4/22!2010 12:34 Signature .-,ti�L _:� .�.... <br />DO NOT WRITE BELOY r THIS LINE i <br />INVENTORY <br />(To t -e completed by collection personnel) <br />Item <br />--- us a rnce hl Filters 92Un1 Total <br />- <br />$0.00 $_ <br />Subtotal� <br />Processing Fee $20.00 ea. $20.00 <br />Total $20 00 <br />