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} ...cvA41dfygio, <br />IL <br />EMVI2n,#IILIiTAi0MIIT,t <br />San Jgaquin CQ, HHW <br />7860 $04th R.A. $rldgeford $t CFSQG DATA; SHEJET & WAIVER <br />Stockton, CA 95208 <br />TOtephone (209) 468,5670 JOB#: <br />Fax:(208) 468-6672 <br />RAnnnnAp <br />131�61010k) <br />State and tedorol hs?ordpUs, waste taws Hm.t th8 use or tris foga pfwa$t41xllipr tlnn FmFl(ams t4 those t�uBings893 that <br />f)p+ldin4e lase then 100 tcligcama {27 gallons ar220 pounds) Of I:azardous wasto par month. Susin"608 that generate more <br />than tills amount ara required by law to use A licensed trazardous waste hauler to manifest and transport their waste. Therefore, <br />In order to partfgpate In this program, you must sign the following Wasiwer of liability, WO reserve the right to review your annual <br />manlfeSta or consult with the County EfIftnmental Hesith Dspadment to determine your 091blllty fbr u6e of this program. <br />Thunk you. <br />I eertify thg business fhat I Mn repnssanting Is a Conditionally Exempt Small +puatttity Generator (CESQG) who generates no <br />mora than 100 kilorams (27 gallons or 220 pound$) of hazardous waste per month basad on an annual average and t, the <br />representative of the CESQQ, understand the maximum quantity of waste accepted at the time for disposal is 27 gallons or z2o <br />Pounds and any disposal costs incurred shall be the responsiblitity of the CF -$4G to pay at the time of disposal. <br />DO NOT WRITE BELOW THIS LINE <br />MrFMTORY <br />(ib be completed by eapedion pemonn <br />ItIAM <br />