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1M arbo <br /> EIfY111Mt110115MAL sERunEs- <br /> San Joaquin Co.HHW <br /> 78W south RA Bridgeford St CESQG DATA SHEET&WAIVER <br /> Stockton,CA 95206 <br /> Telephone(209)468.5670 JOBM 6JIMM66 <br /> Fax:(209)468-5672 SA000046 <br /> eroaw»InFpemation <br /> companyNarne: Stockton Wood Shavings R reeenlaave: <br /> Shoot namesa: 938 East French Camp Road E-mail: <br /> Code: French Camp Ca 95231 red Cote a Taleplxme fr- 209,96&0552 <br /> rad Code G F=Nca low 209-46&1363 <br /> ausimes Weiler <br /> State and federal hazardous Waste laws limit the use of this type Of waste co0eceon programs to those businesses that <br /> generate less than 100 kilgrams(27 gallons or 220 pounds)of hazardous waste per month.Businesses that generate none <br /> than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport Meir waste.Therefore, <br /> In order to participate in this program,you must sign the following wasiver of liability.We reserve&a fight In review your annual <br /> manifests m consult with the County Environmental Health Department to determine your eligibility,for use of this program. <br /> Thank you. <br /> I car*the business that I am representing is a Conditionally Exempt Small Quantity Generator(CESQG)who generates no <br /> more than 100 kilograms(27 galfons or 220 pounds)of hazardous waste per month based on an annual average and I,the <br /> representative of the CESQG,understand the mawnum qua"of waste accepted at the time for disposal is 27 gallons or 220 <br /> pounds and any disposal costs incurred shall be the msponsiblitity of the CESQG lo pay at the time of disposal. <br /> 2/25/2010 1:43 1 <br /> Signature <br /> DO NOT WRRE BELOW THIS LINE <br /> INVENTORY <br /> (To be aHnpieted by collection pereonneq <br /> Item x/lbs./Gel Price Unit Total <br /> Antifreeze 40.d 346 $1.0C gal $40.71 <br /> Subtotal $40.71 <br /> roce"n Fee $20.00 ea. <br /> Total $60,71 <br />