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ElltltlMENTAL I IRMCM <br /> San Joaquin County Permanent HHW Collection Facility <br /> 7850 South RA Bridgeford Street <br /> Stockton,Ca 95206 <br /> Direct:209.468.5670 <br /> Fax:209.468.5672 CESQG DATA SKEET & WATVER <br /> Btaalnesa Information <br /> ConMsny Name(pleaso print) ComCosog Representative forint your name) <br /> streetAddres l/ — <br /> Lity/Soarmp godo Telephone Number <br /> z � ? ( ) (6 <br /> business;waiver <br /> Sutc and federal hazardous wast6 laws limit the use of this type of waste collection programs to those businesses that <br /> generate lea than 100 kilograms (27 gallons or 120 pounds) of hazsrdous waste per month. Businesses that generate <br /> more than this amount aro required by taw to use a licensed bazardous waste hauler to manifest and trattsport their <br /> route.Themtom in order to participate in this program,you must sign the following waiver of liability. We reserve the <br /> rlaht 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 1 am representing is a Conditionally BxmVt Small Quantity Generator (CE.'iQG) who <br /> Stm—tsa no more than 100 kilograms (27 gallons or 210 pounds)of hazardous waste per month based on an annual <br /> average and 1, 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 /> �.: -.o'er✓a:e!. <br /> Date r 7lmo / Si <br /> 1>0 NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Itt rn Gallons Pounds 0 of Cont. Price Total <br /> ,q7 .Q/�✓ <br /> Total <br /> Comments: <br />