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ll Term <br /> MSE ENVIRONMENTAL <br /> a Division of Teris LLC <br /> CESQG DATA SHEET & WAIVER Benicia Office <br /> 3948 Teal Ct.,Ste.B <br /> Benicia,CA 94510 <br /> Business Information Telephone(707)747-5589 <br /> Company Name(please print) ,-,,7— Com any Representative(print your name) <br /> Street Address <br /> City/State2ip Code Tel hone Number <br /> i <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 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 their <br /> waste.Therefore,in order to participate in this program,you must sign the following waiver of liability. We reserve the <br /> right 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 waste per mouth based on an annual <br /> average and 1, the representative of the CESQG, understand the maximum quantity of waste accepted at the tirm 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 Signature. l <br /> -z '' r— I •--- <br /> DO NOT WRTIE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Item Gallons Pounds #of Cont. Price "total <br /> 4. <br /> s a 11 <br /> Total C.`. <br /> Comments: t <br /> G:tEwirieWnw-CFSQOWmNere CA CESQG farmelC d.� AMC wurerandde Onl;e.xle <br />