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. __.,,, n tutus rihLo sENYIars 14002;003 <br /> Banicii Office <br /> 3948 Teal Ct., Ste.B <br /> Benicia,CA 94510 <br /> Telephone(707)7475589 <br /> Fax(707)747-9666 <br /> CONDITIONALLY EXEMPT SMALL QUANTITY <br /> GENERATOR(CESQG)HAZARDOUS WASTE <br /> COLLECTION QUESTIONNAIRE <br /> Listed below are the CESQG Guidelines per California Code of Regulations; 40 CFR <br /> 261.5. Please check the box that applies to your small business: <br /> 1. Does your business generate more than 100 kg/220 lbs. of Yes O No <br /> RCRA&Non-RCRA Hazardous Waste in a month? <br /> 1 Do you accumulate hazardous waste on site? Yes No 13 <br /> If yes,how much is currently stored? 30 �A C <br /> Please print address: V so>J fTtE� — <br /> 3. Does your business use a regular hazardous waste hauler to Yes 13 No ! <br /> manifest and transport your waste? <br /> If ycs,please print time of hauler, type andquantity of waste yo dispose ofper month? <br /> G�� V21icQ 7/ FNJIRUNyI <br /> !� cv Q Alpo 12 *e ('50 n ) <br /> State and federal hazardous waste laws limit the use of this type of hazardous waste collection <br /> program to those businesses that generate less than 100 kilograms(27 gallons or 220 ponds) of <br /> hazardous waste per month. Businesses that generate more than this amount are required by <br /> 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 this document claiming that you are a <br /> Conditionally Exempt Small Quantity Generator. We reserve the right to review your annual <br /> manifests or consult with the County Environmental Health Department to determine your <br /> e-Itg$itTity or m e o t program, <br /> Please read and sign below. <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity <br /> Generator(CESQG)who generates no more than 100 kilograms(27 gallons or 220 pounds) of <br /> hazardous waste per month based on an annual average and 4 the representative of the <br /> CESQG, understand the maximum quantity of waste accepted at the time of disposal is 27 <br /> gallons or 220 pounds and any disposal costs Incurred shall be the responsibility of the CESQG <br /> to the time <br /> of osel. s <br /> Signature <br /> Date <br /> crr�n�LBsQo�EsQc Q ,�.ve <br />