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Vi V., .VV. L1,L 'VU L. <br /> MSEENVIRONMENTAL <br /> 880 Wcsi Verduiera Street <br /> Camarillo.Cil 93010 <br /> Telephone(905)M-0717 <br /> Fax (905)967.8718 <br /> CONDITIONALLY EXEMI PT SMALL QUANTITY <br /> GENERATOR (CESQG)HAZARDOUS WASTE <br /> COLLF.MON QUEST]ONNA IKE <br /> Listcd belotiv a e the (:-'ESQG Guidelines per California Code of Regulations; 40 ('Fit <br /> 261.5. Flease c eck the box that applies to your small business: <br /> I. Does your b siness generate more than I00 k`/220 lbs. of YeS ll No PJ <br /> RCRA & Ni.n-RCRA Hazardous Wasle in a month? <br /> 2_ Does your b siness accumulate more than 100 kg/'220 lbs. Yes 13 No DY, <br /> wilh in a tim period of 90 days? <br /> 3. Do you accu )ulate hazardous waste on site? Yes Er'- No 13 <br /> If no,please Tint address: <br /> 4. Does your bu iness use areQular hazardous waste hauler, Yes ❑ No ❑ to <br /> manifest and trar sport your waste? J <br /> l If yes, please print name of hauler: <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 potinds)of <br /> hazardous waste er month. I3usinesses (bat generate more than this amount are required by <br /> law louse a licen ed hazardous waste hauler to manifest and transport their waste. Therefore, <br /> in order to Parti ipate in this program, you must sign this document claiming that yK arc a <br /> Conditionally Ex m,pt Small Quantity Generator. We reserve the right to review your annual <br /> manifests or con it with the County Environmental Hea)tb )Department to determine your <br /> eligibility for use f this prograsn. <br /> Please react and ign below: <br /> I certify the bu 'ness that I am representing is a Conditionally Exempt Small Quantity <br /> Generator (CIS G) who generates no more than 100 kilograms (27 gallons or 220 pounds) of <br /> hazards Paste per month based on an annual average and 1, the representative of the <br /> CES y, u derst nd the mairnum quantity of waste accepted at the time of disposal is 27 <br /> ga110 is r 20 pot nd and ny disposal a osts incurred sb:all be the responsibility of fire CESQG <br /> to pad t t e time 6f s 1. <br /> 7zZ �z <br /> Signature Vate <br /> 1 <br /> GlFdmsIHF11Y.C1c5Ql:/Ct•:iC' r(?urNiunmve <br />