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--o� <br />Mman <br />CPV V. t A101V <br />-*-7-7 <br />San Joaquin County Permanent HMW Collection Facility <br />7850 South RA Bridgeford Street <br />Stockton, Ca 95206 <br />Direct: 209.468-5670 <br />Fax: 209468-5672 CESQG DATA SHEET & WAI'VER <br />Stastaess information <br />Company Name (pleaso print) ComTany Representative (pzfnt your name) <br />I �a, C Y\- <br />Street Address <br />Luc <br />Cityl3 p Code Telephone Number <br />6q - 1, <br />lowatss waiver <br />State and federal hazardous wastt laws limit the we of tilts typo of waste collection progmrns to those businesses that <br />generate leu than 100 kilograrns (27 gallons or 220 pounds) of hazardous waste per month. Businesses that generate <br />snore than this amount an required by law to use a lioeaaed bazattlms waste hauler to manife6t and tmtsport their <br />warn. Therefore, in order to participate in this program, you mot sign the following waiver of liability. We met" the <br />richt to review your amoral manifests or consult with the County Environmental Health Department to determine your <br />eligibility for use or this progrun. Thank you. <br />aQL4 t+ <br />ao(4 <br />I cattily the business that 1 am representing to s ConditlaWly Exempt Small Quantity Genentor (CE:)'QO) who <br />gmei mwe a* mom than 100 kilograme (27 gallons or 220 pounds) of hazardous waste per month based on an annual <br />avers=e and 1, the representative of the CESQG, understand the maximum quantity of waste accepted it the time of <br />disposal is 27 gallons or 220 pounds and any disposal costs incurred shall be the responsibility of the CESQt3 to pay at <br />tho time of disposal. <br />Item <br />Comments: <br />DO NOT WRITE BELOW THIS <br />UWEMRY <br />(To be completed by collection peraonoel) <br />Gallons Pounds # of Cont. Price Total <br />M, im - — IPM <br />