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EgiFldEE3ONFRIENTAEi-SEIP MELS' <br /> San Joaquin Co.HH1N <br /> 7850 South R.A. Mdgeford Si CESQG DATA SHEET&WAIVER <br /> Stockton,CA 95206 <br /> Telephone(209)468-5670 JOB#- 6.12246338 <br /> Fax:(209)468-5672 <br /> Business Information <br /> Company Name: Amber Land composite Company Representative. Yee Tanti avaron <br /> Street Address: 3632 Duck Creek Drive Building F E-mail: <br /> 7. <br /> CitylstateizP Code: Stockton,Ca 95295 lArea Code s Teleptcone�k 209460-1600 <br /> Area Code&Fax Number 209-460-161.1 <br /> Business Waiver <br /> State and federal hazardous waste laws limit the use of this type of waste collection programs to those businesses that generate <br /> less than 100 kilgrams(27 gallons or 220 pounds)of hazardous waste per month,Businesses that generate more than this <br /> amount are required by law to use a licensed hazardous waste hauler to manifest and transport their waste.Therefore,in order to <br /> participate in this program,you must sign the following wasiver of liability,We reserve the right to review your annual manifests or <br /> consult with the County Environmental Health Department to determine your eligibility for use ofthis program. Thank you. <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator(CESQG)who generates no <br /> more than 100 kilorams(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and 1,the <br /> representative of the CESQG,understand the maximum quantity of waste accepted at the time for disposal is 27 gallons or 220 <br /> pounds and any disposal costs incurred shall be the responsiblitity of the CESQG to pay at the time of disposal, <br /> Date_ 3/27/2009 Signatur <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Item Total Feet #I Ibs.l Gal Price Unit Total <br /> EMPTY DRUM 55GALLON DRUM 0 0 $90.00 EACH $ 10.00 <br /> CONTAINED PAINT WASTE SOLIDS 0 0 lbs. $ - <br /> 0 0 #NIA #NIA $ - <br /> 0 0 MIA #NIA $ - <br /> 0 0 #NIA #NIA $ - <br /> 0 0 #1~I,IA #N/A $ <br /> 0 0 #NIA #NIA $ - <br /> 0 0 #NIA #NIA $ - <br /> 0 0 #NIA #NIA $ <br /> 0 0 #NIA #NIA $ - <br /> 0 0 #NIA MIA $ - <br /> 0 0 q#N/A #NIA $0 0 A $ <br /> Subtotal $ 90.00 <br /> Processing Fee . $ 20.00 <br /> TOtal $ 30.00 <br /> ONE TIME CLEAN OUT PROCESSING LAID ONCE <br />