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�anF�rba <br /> ENgOMENUL SERVICEr <br /> San Joaquin County Permanent HHW Collection Facility <br /> 7850 South RA Bridgeford Street <br /> Stockton,Co 95206 <br /> Direct:209.468-5670 <br /> Fax:209.468.5672 CESQG DATA SHEET & WAI'VER <br /> Bmisess Isformatlon <br /> Corrmrsny Name(please print) Company Representative(print your name) <br /> i2 y-y-c4I') ; <br /> Street Address <br /> 1O3'1 w ITS elv <br /> CitylSb&fLtp Code Telephone Number <br /> Busloew Waiver <br /> State and federal hazardous waste laws limit the use of this type of waste collection programs to those businesses that <br /> gerierste less than 100 kilograms (27 gallons or 220 pounds) of hazardous waste per mouth. Businesses that generate <br /> more then this amount are required by law to use a licensed hwumlous waste hauler to manifest and transport their <br /> waste.Therdor%in order to participate in this program,you must sign the following waiver or liability. We reserve the <br /> right to review your annual manifests or eonauit 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 Genenior (M;Q0) who <br /> generates no more than 100 kilograms (27 gallons or 220 pounds)of hazardoue waste per month based on an annual <br /> average and 1, the representative of the CESQG, underarm the maximum quantity of waste accepted at the time of <br /> disposal is 27 gallons or 220 pounds and any disposal costs incurred shell be the responsibility of the CB8Q0 to pay at <br /> tate time ofdisoosel. -{ <br /> Doti ;2-o <br /> DO NOT WRITE BELOW THIS LINE <br /> INV&NTORY <br /> (To be completed by collection peratmeal) <br /> Item Gallons Pounds NofCont. Price ToW <br /> �/o q I .I <br /> ui 1'5211 .Sar <br /> I . <br /> o O C� <br /> Total <br /> Comments: <br />