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• = Teri P <br /> MSE ENVIRONMENTAL <br /> A division of Teris <br /> CESQG DATA SI3EET & WAIVER Benicia office <br /> 3690 Sprig Street, Suite B <br /> Benicia,CA 94510 <br /> Business Information Telephone(707)747-5589 <br /> Company Name(please print) Company Representative (print your name) <br /> Street Address <br /> City/State/Zip Code Telephone Number <br /> ag"��x` <br /> V , <br /> Business Waiver <br /> State and federal hazardous waste laws limit the use of this type of waste collection programs to those businesses that s 3 <br /> generate less than 100 kilograms (27 gallons or 220 pounds) of hazardous waste per month: Businesses that generate <br /> more than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport then <br /> waste.Therefore,in order to participate in this program, you most sign the.following waiver of Itabdity. We reserve rhe -� ,, �k^ak <br /> right to review your annual manifests or consult with the County Environmental Health Department to determine your s$ <br /> eligibility for use of this program. Thank you. �� s •,xa , <br /> I certify the business that Lam representing is a Conditionally Exempt Small Quantity Generator (CESQG) who ^ <br /> generates no.more than.100 kilograms (27 gallons or220pounds) of_hazardous waste per month based on,anannual s- <br /> average and.I,.the representative of the CESQG, understand the maximum quantity of wasteaccepted at the time of $ - <br /> osts incurred shall be the responsibility of the CESQG to pay at <br /> disposal 27 gallons or 220 pounds and any disposal c <br /> y, the time of disposal <br /> Dale Time Si��n/(allure <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection.Personnel) <br /> P`�°i\S..x f£ tiro r uivX*.45. E ✓1.ra .� "]1�.,` <br /> Tien Gallons Pounds #of Cont. Price Total <br /> 1 <br /> R. <br /> F+; <br /> ya 6?a4 <br /> k <br /> Total ' w4 <br /> Conurents: <br /> �x r� <br /> 4 <br /> 3�Sr'f�l I 'b3. <br /> Y !` ext A key: <br /> n�� i <br /> 4 <br /> GAEorn,sV1nw-0ESQG\Nonhem CA CESQG roans\CZSQG du[a sheet&w,1111.,Ben cm Office.xle `+- ' <br />