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Te r i <br /> I\4SE ENVIRONMENTAL <br /> A division of Teris <br /> CESQG DATA SHEET & WAIVER Benicia Office <br /> 3690 Spl Ig Street,Site B <br /> Benicia,CA 94510 <br /> Business Information Telephone(707)747-5589 <br /> Company Name(Blease print) Company Rcpresentjitive(print your name) <br /> Street Address <br /> City/State/zipYCode ` Telephone Number <br /> Business 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 kilograms (27 gallons or 220 pounds) of hazardous waste per month. Businesses that generate <br /> morecthan this amount are required bylaw to use a licensed hazardous waste hauler to manifest and transport their <br /> waste:Therefore,in order to participate in this program,you must sign the following waiver of liability. We reserve the <br /> right to review your annual manifests oiconsult with the County Environmental IIealth Department to determine your <br /> eligibility for use of this program.Thank you. <br /> I.certify the business that I alit representing is a Conditionally.Exempt Small Quantity Generator (CESQG) who <br /> generates no more than 100 kilograms (27 gallons or 220 pounds) of hazardous waste per month based oil an annual <br /> average and I, the representative of the CESQG, understand tile maximum quantity of waste accepted at the time of <br /> disposal is 27 gallons or 226 pounds and any disposal costs incurred shall be the responsibiluy of-;Ihe CESQG to pay at <br /> the lune of disposal. � ' �i r• w ' <br /> t .dl <br /> Date Time Signature i:. <br /> 4 <br /> DO NOT WRITE BELOW T141S LTTE <br /> INVEN'T'ORS, <br /> fCo be completed by collection personnel) <br /> Rein Gallons Pounds #t of Conti Price Total <br /> TOI�aI J - <br /> (i:\P6rm5Vlll\VL[$Qf\KrxiLcrn G\f1iSQf(orinslCr:SQG d�ir rhttrR c:u cr urn n.Oflcc:xla <br />