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Ie�amHa�rbo <br /> San Joquln Co.HHVJ <br /> 7850 South R.A.eridgetord St CESQG DATA SHEET&WAIVER <br /> Stockton,CA 95206 <br /> Telephone(209)488-5670 JOEW- <br /> Fax:(209)468-5672 SAOOOW <br /> valitees Infommoon <br /> Nap Re va; <br /> easel nddr—,,: X E-mail: <br /> GlyiSt,t,ZpCWd: Arae Code&T hone#: 020 3 <br /> .�A.4, * roe Code&Fax Number <br /> Business Walvor <br /> State and federal hazardous waste Yaws Amit the use of this type of waste collection programs to those businesses that <br /> ganarals less than 100 kpgrems(27.9010M or 220 pounds)of hazardous waste per month.Suslness rs that generate mono <br /> Man this amount ane required by law to use a Iloensed haranious waste haulet to manifest and transport their waste.Therefore, <br /> in order to partict"in this program,you must sign the following wasiver of liabllity.We resew the right to ravlew your annual <br /> manNests or consult with the County Envgonmental Health Department to determine your eligibility for use of this program. <br /> Thank you. <br /> 1 cerit y the busimss Mat I am representing is a Conditionally Exempt Small Ouan*Generator(CESGG)who generates no <br /> more than 100 Idlorams(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and 1,the <br /> mpresentativa of the CESQG,understand the maximum quantity of waste accepted at the time for disposal Is 27 gallons,or 220 <br /> pounds and any disposal costs Incurred shop be the responsibfNty of the CESQG to pay at the time of disposal. <br /> 9. 30 <br /> , /a ;0 J Signatu <br /> DD NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To ho Completed by ookotlon personnel} <br /> Item p/les./Gal Price Unk Tole) <br /> `� // { <br /> Subtota <br /> kracessaing Fee t, 1711 Wo 0 ea. <br /> Tota <br /> IV <br />