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,,aquin permanent Collection Facility <br /> .8,__--,outh R.A Bridgeford Street <br /> itookton,CA 95206 <br /> )fired: 209-468.5870 <br /> :ax: 209-468-5672 CESQG DATA SHEET &WAIVER <br /> M <br /> x� S 7A- 1 b"V <br /> suainess waiver <br /> State and federal hazardous waste laws limit the use of this type of waste collection programs to those s that businesses the <br /> generatfthan thisi less than amount are per month. Businesse <br /> required equllgred by law90 luso a I;canons or Osed haze dous waste hauler pounds)of hazardous to o man f sl and transport their waste.ta more <br /> wasiver o <br /> Therefore, determine your eligibility for use of this <br /> In order to participate in this program,you must sign the following f liability. We reserve the right to review <br /> your annual manifests or consult with the County Environmental Health Department to <br /> program. Thank you. <br /> ionally Exempt ty <br /> (CES <br /> G)who <br /> es <br /> more than too kilore sa(27 gallons or 220 pounds)ofthazardous waste per month lbased on aon annuaQ average andrlallheno <br /> al 27 <br /> is <br /> representative o <br /> you ds andfany disposal costs incurred shallbe thethe CESQG, understand the mimum grespo'ns blititysof the CESQG to p-cepted at the ame ti <br /> ac <br /> y atthetime ofldisposa�l. or <br /> Signature <br /> Date Time /S M <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Gallons Pounds #of Cont. Price ca !� <br /> Item z r,SO .5�, <br /> �a <br /> 2-2— <br /> Sub <br /> —ZSub total $20.00 <br /> Process fee <br /> Total <br /> i Comments: <br />