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leanwo <br /> K I1fM01Ml6TA16t91g1 <br /> San Joaquin County Permanent HHW Collection Facility <br /> 7850 South RA Bridgeford Street <br /> Stockton,Ca 95206 <br /> Direct:209.368.5670 <br /> Fax:209468. <br /> Seinen latormitiea CESQG DATA SHEET & WATVER <br /> atl <br /> m Ntme(plwo 'nr Comp my Reptoeentative,(print your name) <br /> s <br /> S <br /> City/3 aTelephono Number <br /> ( ) <br /> Business Waiver <br /> State end Metal hazardous waste laws limit the use of this type of waste collection programa to those busineaa that <br /> generate lea thin 100 kilogram (27 pitons or 220 pounds) of hazardous waste per mouth. Businesses that genente <br /> mitre than Ail amount are required by taw to use a licensed hazardous waste hauler to manifest and transport their <br /> wane.Therefore,in order to participate in this progtm,you must sign the following waiver or liability. We receive the <br /> right to review your annual msmffesa or consult with the County Environmental Health Department to determine your <br /> eligibility for use or this program,Thank you, <br /> I csrtlry the business that I am tepi onting is a Conditionally Exempt Small Quantity Generator (CESQ0) who <br /> geasrata no more than 100 ktlognms (27 gallons or 220 pounds)of h=md0us waste per month based on an aonual <br /> average and I, rhe representative of the CtESQG, understand the maximum quantity of waste accepted at the tim of <br /> dlspaal is 27 gallons or 220 pounds and any disposal costa tacurred shell be the responsibility of the CESQ0 to pay at <br /> tho time ofdisoosal. <br /> Dare Time Si <br /> -a 9.6 <br /> DO NOT WRITE BEL THIS LIMB <br /> INVENTORY <br /> (To be completed by collection paravnnel) <br /> Item Gallons Pounds NofCow. Pncc Total <br /> v / gib 3 <br /> r <br /> Total v <br /> Commema: <br />