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05�ZZ�206$ 08: 50 2094-38567 <br /> CLEAN HARBORS PAGE 03/05 <br /> San Joaquin County Permanent FHHW Collection Facility <br /> 7850 South KA Bridgeford Street <br /> Stockton,Ca 95206 <br /> Direct:209-468.5670 <br /> Fax:209-468.5672 <br /> CONDITIONALLY EXEMPT SMALL QUANTITY <br /> GENERATOR(CESQG)HAZARDOUS WASTE <br /> COLLECTION QUESTIONNAIRE <br /> Listed below are th CESQG Guidelines per California Cods of Regulationsi 40 CFR <br /> 261.5. please check the box that applies to your small business: <br /> 1. Does your busin s generate more than 100 k020 lbs. of Yes 0 No <br /> RCRA&Non-R RA Hazardous Waste in a month? <br /> 2. Do you accutnul a hazardous waste on site? Yes No 0 <br /> If yes,how much is currently stored? <br /> Please print a�dt ss: w 1l <br /> 3. Does your busine$ls use a regular hazardous waste hauler to Yes 0 No Ar, <br /> manifest and transport your waste? <br /> If yes,please p . name of hauler,type and quantity of waste you dispose of per month? <br /> State and federal harArdous waste laws limit the use of this type of hazardous wwte collection <br /> program to those bus eases that generate less thein 100 kilograms (27 gallons or 220 pounds)of <br /> hazardous waste per onth. Businesses that generate more than this amount are required by <br /> law to use a licensed azardous waste hauler to manifest and transport their waste. Therefore, <br /> in order to ps rtieipat in this program, you must sign this document claiming that you are a <br /> ConditionallyExemp Ith <br /> mall Quantity Generator. We reserve the right to review your annual <br /> manifesto or onsult the County Environmental Health Department to determine your <br /> eligibility for Ose of th s program. <br /> 'lease read a d sign elow: <br /> I certify the alines that I am representing is a Conditionally Exempt Sm911 Quantity <br /> Generator(CESQG) ho generates no mnore than 100 kilograms (27 gallons or 220 pounds) of <br /> hazardous waste per month based on an annual average and I, the representative of the <br /> CES�QG, understand he 'maximum quantity of waste accepted at the tune of disposal is 27 <br /> gallons or 220 oands nd any disposal costs incurred shnil be the responsibility of the CESQG <br /> to pay at the d a of d sal. <br /> i <br /> L <br /> Si ature Date <br /> C�/ForrotlRFfVV.CgS t nnniee ��' <br />