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�TSFRTy�go <br /> leaavuwlrlarr+h�sir �/CFS lig <br /> Sal Joaquin Co.HIM <br /> 7850 South RA Bridgeford St CESQG DATA SHEET&WAIVER <br /> Stockton,CA 95206 <br /> Telephone(2D9)468-5870 JO&y: <br /> Fax:(209)468-5672 SAODD046 <br /> penNamr. .-\J� R �vtv� _ois.0 <br /> Add.: .y �iU` E-mail: <br /> Code: <br /> 1\_o \ S' _. t `) res Code 87 el W ione«: .-' _L .��` 1\ <br /> res Code&Fac Nmnber T,jt <br /> 111"Wass yyah r <br /> State and federal hazardous waste laws limit the use of this type of waste collection Prognanns to those businesses that <br /> generate Ins than 100 Morems(27 g~s 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-Therefore. <br /> in order to participate in this pmgmn,you must sign the following washer of liability.We reserve the right to review your annual <br /> manifests or ran"with the Camty Environmental Health Department to determine your eligibility for use of this program. <br /> Thank you. <br /> I oartHy the business that I am representing is a Conditionally Enaampt Smag Ouantiry Generator(CESOG)who generates no <br /> more Man 100 kBarams(27 gallons or 220 pounds)of hazardous waste per month based on an armuai avere0e all 1,the <br /> representative of the CESOG.understand the maximum quantity of waste accepted at the time for disposal is 27 gallons or 220 <br /> pounds and arty disposal costs Vw urred shag be the responsibin ity of the CESOG to pay at the time of disposal. <br /> gnatu:e „� <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by oose personnel) <br /> from a I lbsJ Gal Price Una Total <br /> t-,r, L_.- -, 7/ 1,; S Jt ,, I I qk- 2"7 <br /> Subtota b 2 7 <br /> Processing Fee 320.00 ea. <br /> Tota IS <br /> - r <br />