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barbLor 5 <br /> EMMItieMMENTAIA..SERVICES" <br /> San JaRquIn Cn MHN( <br /> 7850 Srarrl R.A Bridgafnrd St CF_-qQG PLATA SHEET R WAIVER <br /> Stockton, CA IMM <br /> Telephone(209)468-5670 ,1088: 6.12728788 <br /> Fax.(209)ASS 5672 SA000046 <br /> BusirmssComport Nema: Payless CompanYRspresemtl*" Frank Pelko <br /> 3Y — <br /> streetaedreao: 26 No Cherokee Le Suite B E-mail: <br /> CiiYri3tata/Zip Code: LOtlI Ce 862A0 <br /> real Code&Tal horro ii. 288-334.3112 <br /> Area Code&Fax Number <br /> gmte,ane iedar <br /> State and tedeml hazardous waste laws Ilma the use of this type of waste collection programs to those businesses that <br /> genemte less than 100 kilograms 127 gallnnn or 220 pounds)of hazardous waste per month.Businesses that generate more <br /> than ihls amount are requited by law In use a licensed hazardous waste banter to manifest and transport their waste.Therefore, <br /> In nrdar to padicfpate in this program,you must sign the following waiver of(lability.We reserve the right to review your annual <br /> manifests or consult with the Gounly Environmental Health Department to determine your eligibility for use of this program- <br /> Thank you. <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity Cenemfor(CESQ(3)who generates no <br /> more.than ton idlogralms(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and 1.the <br /> mprelsenrative of the CFSQG,understand the maximum quantity of waste accepted at the lime for disposal is 27 gallons or 220 <br /> pounds and any disposal costs incurred shall be the responsibility of the CESQG to pay at the time of disposal. <br /> Signature -° <br /> a✓1o�2oto �toa <br /> 00 NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To tw completed by nnloolon perannna) <br /> Item A/ba/Gal Ptica Un0 Total <br /> Flammakfle Solid 47 $1.8 lbs $75.20 <br /> oor sivee <br /> f- <br /> etal shavi_nV,,,,,.� <br /> Fluorescent Lampe _ 14 $0.7 lbs. <br /> �T- -- Subtotal $85.00 <br /> $20.00 ea. <br /> roceeein Fee $105.00 <br /> Tota <br />