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Term <br /> sC ' LA �Q� ��� 4ISE ENVIRONMENTAL <br /> Jt ILI'�11 division of Tens <br /> CESQG DATA SHEET & Benicia office <br /> MAR 1 5 [006 3948 Teal Ct.,Ste.B <br /> Benicia,CA 94510 <br /> Business Information VIRONMENT HEALTR-ephone(707)747-5589 <br /> C y Name(p a prin C mpany Re ur name) <br /> r 1 <br /> Street Address 1 <br /> CqQ <br /> •p Cod r=f'Trele hone Number <br /> o > Cfl4�l 1 <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 /> more than this amount are required by law 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 or consult with the County Environmental Health Department to determine your <br /> eligibility for use of this program Thank you. - <br /> I certify the business that I am 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 on an annual <br /> avenge and L the representative of the CESQG, understand the maximum quantity of waste accepted at the time of <br /> disposal is 27 gallons or 220 pounds and any disposal costs incurred shall be the responsibility of the CESQG to pay at <br /> the time of disposal. <br /> De Time Ifignatre <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Item Gallons Pounds #of Cont. Prie Total <br /> .rJ � <br /> ITV; <br /> l <br /> tal <br /> Comments: <br /> O.TonuUnnw-MQCWpthera CA CESQG For CESQG dam sheet&vetiver-aeoicia Orr--I- <br />