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San Joaquin County Permanent HMW Collection Facility <br />7850 $outh RA Bridgeford Street <br />Stockton, Ca 95206 <br />Direct: 209.468.5670 <br />Fax: 209.468.5672 CESQGDA`T'A SMERT & WAIVER <br />BUISM tttomatles <br />pay am (pita print) �-, Company Rept�atentattve (print your name) <br />f f4 Z. �% 1 <br />tt+setAddreu r <br />. X33 rd .r¢ <br />at/ylBtueJZip Code �j _ Tdophoits Neambark1461 eq ) <br />Wslver <br />Shit and t R21 hazardous supers Inmos limit the we of 11113 TM of waste collection prognj= to those busfneasa that <br />Staerate las do 100 kilo (27 gallant or 220 pounds) of hazardous weste per month. Businesses that joerate <br />:Dore than tilt amount era required by taw to rue t li bszardous waste haular to mini fest end =Isport their <br />tirsste, Thaofora, in order to participate In this progtram, you smear sign the following waiver of liability. Wt reserve the <br />algal totvview your annusl numifeM or consult with the County BnvimnmentsI Health Departmeat to deternttne your <br />AWRY for on of this programa. Thant you, <br />I c City the business that I am reprastmtt49 it S Coaditiatully Bxtmtpt Small Qmtity Qenentor (MIQ0) wbo <br />Swam oe mom that 100 Idtogt=s (27 jAlous of 220 ponds) of hazardous waste per month based on an =VW <br />XVOPP ted t, the re fcMtati" of the CBSQ4, uudaatand rho tttatimtnn quantity of waste tecetned it the time of <br />dtsposat is 27 gallons or 220 pounds and any disposal coats iaoarrod :bili be the responsibility of the CB9Qt3 to Sty It <br />the tine ofdisoosal. <br />INv8N'i'ORv <br />(To bo aomploted by oaitoction paremael) <br />