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UI I VL/LVVL .1 LI, I .11': ti <br /> N15L LNVIP ONN IF..NTAL <br /> CESQG INVENTORY FORM 880 West Verdctcra Street <br /> Camarillu.CA 93010 <br /> Tclepliorre(805)987-0217 <br /> Fax (805)957-8715 <br /> Company Mame: (brPl 4LL)S-1a-l"Tunl3Ct: 9,l �W,zrS <br /> A ddre,s,� i57t/ — <br /> _ <br /> City: 7_ap Code4<2,031�67 Phonc No.: <br /> County= w 'k, <br /> Event Location/Dat (if know ._� <br /> To be filled out by <br /> Type of Waste Quantity Size and Type Liquid/ NISI; <br /> of Container 'SO fid Curt PeT Total Cost <br /> Ib/gal. <br /> (exarnple):Latex Pui t 4 — 5 gal plastic Liquid <br /> JJ __ bucket <br /> Sub Total <br /> m Processing Fee <br /> Total 2aid hj the S onsoring,Agenc <br /> _ Total to be paid by CESQGif you need more roo►u+please attach another sheet and list as specified on this form. <br /> *Some sponsoring: a lencies may subsidize a part of the disposal costs, please call (805) 987-0217 i[ <br /> you'd like rnore infonntion. <br /> I certify the busines that I am representing is a Conditionally Exempt Small Quantity Generator <br /> (CESQG) who-gene r <br /> ho gener tes no more than 1001dlograms(27 gallons or 220 pounds) of hazardous waste <br /> per month based on an annual average and 1, the representative of the. CESQG, understand the <br /> tnaxiurl a quantity r f waste accepted at the time of disposal is 27 gallons or 220 pounds and any <br /> dis 'sa coSis incurr d shall be the rrsponsibility of the C1rSQG to pay at the time of disposal. <br /> 62 <br /> Signature 6.1te <br /> rrnorm.n;rnv.C.r•SQC,CESQC mcn�or7 foR1�1 <br />