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ENVIRONMENTAL SERVICES' <br /> San Joaquin Gn.HHW <br /> 7050 South R.A Bridgeford St CESQG DATA SHEET&WAIVER <br /> Stockton,CA 95206 <br /> Telephone(209)468-5670 JOB#_ 6.12820636 <br /> Fax!(209)468-5672 SA000046 <br /> Business Information <br /> Company Name: Stockton gotf and country club 1cornpany Re resentauve: Jim alwine <br /> Street Address: 3800 w country club blvd E-mail: <br /> C /Stet Code: stockton,ca 95204 Area Code s Telephone e: 209-462-6734 <br /> rea Cade 8 Fax Number <br /> Business Waiver <br /> Stale 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 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 program,you must sign the following waiver of liability_We reserve the right to review your annual <br /> manifests or Consult with the County Environmental Health Department to determine your eligibility for use of this program. <br /> Thank you. <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator(CESQG)who generates no <br /> more than 100 kilograms(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and I,the <br /> representative of the CESQG,understand the maximum quantity of waste accepted at the time for disposal is 27 gallons or 220 <br /> pounds and any disposal costs incurred shall be the responsibility of the CESQG to pay at the time of disposal. <br /> 8/20/2010 Signature <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Item #/lbs./Gal Price Unit Total <br /> flammable solid 26 1.60/lb $41.60 <br /> flammable liquid 51 5.30! al $31.80 <br /> Subtotal $73.40 <br /> Processing Fee I 1 $20.00 ea. $20.00 <br /> Tata I I 1 $93.40 <br />