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CESQG DATA SHEET & WAIVER <br /> San Joaquin CountyHousehold Hazardous Waste Collection Facility <br /> 7850 South R.A Bridgeford Street, Stockton, CA 95206 <br /> Phone: 209-468-3066 Fax:209-468-3078 <br /> Business Information <br /> Com an Name(please print) Company Representative(print your name) <br /> e n(�rti <br /> 8tr et Address <br /> C AAAf eA 4 <br /> City/ tate/Zip Code Area Code&Telephone Numbs <br /> olc < ch C,g 9s�ay1 _ SY7- s�y <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 kilgrams(27 gallons or 220 pounds)of hazardous waste per month. Businesses that generate more <br /> than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport their waste. <br /> Therefore, in order to participate in this program,you must sign the following waiver of liability.We reserve the right to review <br /> your annual manifests or consult with the County Environmental Health Department to determine your eligibility for use of this <br /> program. Thank you. <br /> 1 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 /> average and I,the representative of the CESQG, understand the maximum quantity of waste accepted at the time to <br /> disposal is 27 gallons or 220 pounds and any disposal costs incurred shall be the responsiblitity of the CESQG to <br /> pay at the time of disposal. <br /> Date Time Signature <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY q 1 i -1 <br /> (To be completed by collection personnel) I � <br /> Item Gallons Pounds #of Cont. Price Total <br /> �rU(.-Crs.:. • �PZ. .� 7 U. rJe� Z.G. C76 <br /> Total <br /> lOo <br /> Comments: <br />