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:\L•IUI LUUL I i �t i IVlil <br /> V+ VL.r I-VVI- i LCL' I \YU VU !Q 003/003 <br /> �n MSL 1:NVLtONM1:.NTAL <br /> CCSQG INVENTORY FORM 880 West Vdvdulcro 5ereet <br /> Camas-111U.CA 93010 <br /> L V 1 o Fax(805)987.871E <br /> Company Name: (Sr <br /> � <br /> Addrrssj O <br /> City- zip Code.S� `/d7 Phone No,: <br /> County: %A, <br /> Eveni Location/Datc (i know <br /> .�.~ To be filled out by <br /> Type of W Lie Quantity Size and'Type Liquid/ N1SE <br /> of Container Solid Cost per' Taal Cost <br /> -� Ib.lgat. <br /> (example):larox Paint 4 5 gal plastic Liquid <br /> backet <br /> /4W Ail <br /> cir <br /> tic v4•�c � Mi5 e r - �� a <br /> Sub Total L CJ <br /> Processing'Fee_ <br /> Total Paid bX the Sponsoring ARenc <br /> TOW to be psid by CES G <br /> It you flaed more room ple a otucb mnother 5hcet and list as specified on this farm. <br /> `Sonic sponsoring agencl may subsidize a part of the dis ;d costs, please call (805) 987-0217 if <br /> you'd like marc iinTorTnat ova, <br /> I certify the business thai I am representing 6 a Conditionally Exempt Small Quantity Gerletfitor <br /> (CESM who'gencratcs�o more than IN leilograms(27 gallons or 720 mounds)of hazardous waste <br /> per monUt based on an IMUS! average and r, the representativo of the CESQG, understand the <br /> ititjxj u)ti quantity of wa�te aecekted ai the time nr disposaI is 27 galloas ur 220 pounds and any <br /> (lis sa cots incurred 6h t be the raspvnsibilit)- of the CLSQG to pay at the tinge of disposal. <br /> Signature gate JZ <br /> 70rvI.vI3INV.CPSQ0IC£SQC In—wer to%") <br />