Laserfiche WebLink
TeriP <br /> MSE ENVIRONMENTAL <br /> CESQG DATA SHEET & WAIVER Benienkiia aonof Tens LLC <br /> Office <br /> 3948 Teat Ct.,Ste.B <br /> Beoicia,CA 94510 <br /> Business Inforvution Telephone(707)747-5589 <br /> Company Name(Please print) any Represenmtive(print y panne) <br /> 7 1 <br /> Street Address <br /> C ti <br /> C7tY/StatdLtp Code TelRhone Number <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 tun a licensed hazardous waste hauler to manifcat and transport their <br /> waste.Therefore,in order to participate in this program,yon must sign the following waiver of liability. We reserve the <br /> right to review your annual manifests or consWt 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 Generamr (CESW) who <br /> generates no more than 100 Idlogruns(27 gallons or 220 pounds)of hazardous waste per month based on an annual <br /> average and 1, the representative of the CESW, 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 Sign*"re <br /> L <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Item Gallons Pounds #of Cont. Price Total <br /> ... <br /> Total <br /> h- <br /> Comments: <br /> G'WameW ESQGW=veru C CPSQG toll.CI&SQn G.w I a river.&deity Offzxit <br />