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Teri <br /> MSE ENVIRONMENTAL <br /> CESQG DATA SHEET & WAIVER Benicia Office ecia LLC <br /> 3948 Teal CL,Ste,B <br /> Benicia.CA 94510 <br /> Business Information Telephone(707)747-5589 <br /> Company Name(please print) Company Represemative(print your name) <br /> r1 1 <br /> Street Address <br /> Ic <br /> Ci S teMp Code To hone Number <br /> G O ( )meq <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 kilograms (27 gallons or 220 pounda)of hazardous waste per month. Businesses that generate <br /> more than this amount are requited by law t0 use a licensed hazardous waste hauler to manifest and transport then <br /> waste.Therefore,in order to participate in this program,you must sign the following waiver of liability. We reserve the <br /> rigbi 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 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 wasse 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 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 /> the time of disposal. <br /> Date Time Si <br /> DO NOT WRrM 13MOW TILS LINE <br /> INVENTORY <br /> Cro be completed by collection personnel) <br /> Item Gallons Pounds #of Cont. Price Total <br /> total00 <br /> J <br /> t <br /> Comments: <br /> G.lrwmeWHwf'F_SQGWpaa�a CA CESQG fa, IItQa a.0 Jai k W,I -lt a &Ori..h 4 <br />