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too 00%10 <br /> EIIIHtOIaIeAA1L SlRfIlyEr <br /> San Joaquin County Permanent HHW Collection Facility <br /> 7850 South PA Bridgeford Street <br /> Stockton,Ca 95206 <br /> Direct 209468-5670 <br /> Fax:209-468-5672 <br /> CONDITIONALLY EXEMPT SMALL QUANTITY <br /> GENERATOR(CESQG) HAZARDOUS WASTE <br /> COLLECTION QUESTIONNAIRE <br /> Listed below are the CESQG Guidelines per California Code of Regulations; 40 CFR <br /> 261.5. Please check the box that applies to your small business: <br /> 1. Does your business generate more than 100 kg/220 lbs. of Yes O No 01 <br /> RCRA &Non-RCRA Hazardous Waste in a month? <br /> 2. Do you accumulate hazardous waste on site? Yes f� No C3 <br /> If yes,how much is currently stored? <br /> Please print address: r7 <br /> C ✓� C l 1� a'1 >> <br /> 3. Does your business use a regular hazardous waste hauler to Yes o No O <br /> manifest and transport your waste? <br /> If yes, please print name of hauler, type and quantity of waste you dispose of per month? <br /> Zvi <br /> State and federal hazardous waste laws limit the use of this type of hazardous waste collection <br /> program to those businesses that generate less than 100 kilograms (27 gallons or 220 pounds) of <br /> hazardous waste per month. Businesses that generate more than this amount are required by <br /> law to use a licensed hazardous waste hauler to manifest and transport their waste. Therefore, <br /> in order to participate in this program, you must sign this document claiming that you are a <br /> Conditionally Exempt Small Quantity Generator. We reserve the right to review your annual <br /> manifests or consult with the County Environmental Health Department to determine your <br /> eligibility for use of this program. i` a ; CL <br /> (f <br /> Please read and sign below: <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity <br /> Generator (CESQG) who generates no more than 100 kilograms (27 gallons or 221) pounds) of <br /> hazardous waste per month based on an annual average and I, the representative of the <br /> CESQG, understand the maximum quantity of waste accepted at the time of disposal is 27 <br /> gallons or 220 pounds and any disposal costs incurred shall be the responsibility of the CESQG <br /> to pay at the time of disposal. <br /> Signature Y) CL Date <br /> G/FomisMHW-CESQG/CESQG Questionnaire <br />