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n <br /> RECENED - Terif <br /> MSE ENVIRONMENTAL <br /> ,II IL. - 7 2005a Division of Teris LLC <br /> CESQG DATA SHEET &WAIVER Benicia Office <br /> ENVIRONMENT HEALTH 3948 Teal Ct.,Ste.B <br /> EERMIT/SERVICES Benicia,CA 94510 <br /> usmess Information Telephone(707)747-5589 <br /> Company Name(please print) r— Company Representative(print your name) <br /> kf i it C J rQc; /c7 /'i���: Y f: f_ / , y j fir.'. Y.L �e <br /> Street Address <br /> ,;- -`� 7_ Ll, /( 1 <br /> City/State/Zip Code r Telephone 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 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 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 Signature <br /> 4 S P <br /> G as s A ( <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 /> FL f.•,, sir 46 R•:J s��f: c_ /C�•, �. �r� �• , '� 1.-^. <br /> Total = '% <br /> Comments: <br /> G:Torms\HHW-CESQGNorthcrn CA CESQG forms\CESQG data sheet&waiver-Benicia Office.xls <br />