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uuiuo;cuuv tout me TER1S FIELD SERVICES f�003/003 <br /> Benicia Office <br /> 3948 Teal Ct.,Ste.B <br /> CESQG INVENTORY FORM Benicia,Ch 94510 <br /> Telephone(707)747-5584 <br /> Fax(707)747-9666 <br /> Company Nameh: r RC+ Z To(2A G q Contact <br /> Address: D ( A), Ak}}/-s�—• / <br /> City: D� r oIj Zip CodeS� Phone No.: ) h 99-1 <br /> County: rte/ O Ago) iJ "EPA Il) <br /> "If you do not ve an EPA ID#,you may call(800)618.6442 to obtain one. <br /> Event LocaationMate(if Imown): <br /> Type of Waste Quantity <br /> be filed out by,tity ,Size and Type Liquid/ Teris <br /> Of Container Solid Costpa Total Cost <br /> (bind. <br /> (eraayskJ:LarexPaiar 4 S gal plasYrc Liquid <br /> i <br /> bucket <br /> I <br /> Slob Total <br /> -- Fee <br /> — -- --- ------- <br /> TOW!R be ald b CESQG — <br /> If you need more room please attach another sheet and lat as sped ice on this term. <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator <br /> (CESQG)who generates no more than 100 kilograms(27 gallons or Z20 pounds)of hazardous waste <br /> per month based on an annual average and I, the representative of the CFSQG, understand the <br /> maximum quantity of waste accepted at the time of disposal is 27 gallons or 220 pounds and any <br /> disposal costs incurred&hail be the responsibility of the CESQG to pay at the time of <br /> disposal. <br /> Signature <br /> Date <br /> rJ>�IWWw-CEeQQTXs 1...m.rsoaas <br />