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FROM FAX NO. "lar. 09 2009 03:48PM P3 <br /> [lemHarbors <br /> ENVIRONMENTAL SERVICES" <br /> San Joaquin County Pemtanent HHW Col Facility <br /> r8W South R A Brkkldord Street <br /> Stockton,CA 952W <br /> Direct` 20,4466-5670 <br /> Fax 209-468-5672 <br /> CESQG DATA SHEET&WAIVER <br /> Srnlnmm Irdorngtlon <br /> SB Gas & Market Kerr Cook <br /> 515W11thSt <br /> Tracy Ca 95376 209-834-8838 <br /> Businees Waiver <br /> es" hat <br /> State and federal hazardous waste taws limit the use of this type of waste con ection programs h. ott�busit generale more <br /> generate less than 100 Idlgrarns(27I'Igagons or 220 pounds)of hazardous waste per <br /> than this amount are required by law to use a Licensed hazardous waste hauler to manifest and transport their was to review <br /> Therefore, in order bD participate in this program,You must sign the following wasiver of liability.We reserve the rig <br /> ht <br /> ronmental Heakh Department to determine your eligibility for use of this <br /> your annual manifests or consult with the County Envi <br /> program. Thank you. <br /> I certify the business that 1 am representing is a Conditionally Exempt Small Quantity Generator(CESQG)who generates no <br /> more than 100 kilorams(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and I,the <br /> representative of the CESUCC,un at the time to disposal is 27 gallons or 220 <br /> nit the maximum quantity of waste accepted at the time of disposal. <br /> pounds and any dispose!costs incurred shall be the responsibli ity of the CESQG to pay <br /> 3/6/21709 11:11 AM Signature <br /> Do NOT WRITE BELOW THIS LINE <br /> IPMNTORY <br /> (To be completed by colietcoon Personnel) <br /> Item GallonsPounds s of Cont. Prig TOL <br /> FluorwerA Lamp 8 0.70 5.60 <br /> 5.60 <br /> Sub total $20.00 <br /> Process fee <br /> _ $25,60 <br /> Taal <br />