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05/29/2008 11: 46 2099316743 IrJATERL00 SHELL PAGE 02 <br /> IE NMEWAL NAMES* <br /> San J in County Permanent HHW Collection Facility <br /> 7850 S4 Ah R.A Bridgeford Strest <br /> Stockto ,CA 95208 <br /> Direct: 09-4685670 <br /> Fax 09-4885672 <br /> CESQG DATA SHEET 8t WAIVER <br /> Ines Information <br /> 'Waterloo Shell Food Mart & Car WashBili EPA# CAL 000270806 <br /> 315 E_ Waterloo Rd <br /> tockton Ca 95205 209-931-3674 <br /> usines Waiver <br /> tate and federal hazardous waste laws limit the use of this type of waste collection programs to those businesses that generate <br /> than 100 kilgrams(27 gallons or 220 pounds)of hazardous waste per month. Businesses that generate more than this <br /> Dunt aro required by law to use a licensed hazardous waste hauler to manifest and transport their waste.Therefore, in order to <br /> articipate in this program, you must sign the following wasiver of liability.We reserve the right to review your annual manifests or <br /> nsult with the County Environmental Health Department to determine your eligibility for use of this program. Thank you. <br /> t <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator(CESQG)who generates no <br /> inore than 100 kilorams(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and I,the <br /> presentative of the CESQG, understand the maximum quantity of waste accepted at the time fo disposal is 27 gallons or 220 <br /> liounds and any disposal costs incurred shall be the responsiblitity of the CESQG to pay at the time of disposal. <br /> i <br /> 5/29/2008 11:00 AM I Signatur <br /> DO NOT WRITE BELOW THIS LINE <br /> i <br /> INVENTORY <br /> f (To be completed by collection personnel) <br /> 2 <br /> m Gallons Pounds f of Cont. Price Total <br /> uel Filters 24 24 1.00 24.00 <br /> lammable Liquids Brine Water 27.0 230 2 5.00 135.00 <br /> lamSolid absorbent 52 1 1.50 78.00 <br /> lammable Liquids (gasoline) 2.5 21 1 5.00 12.50 <br /> 249.50 <br /> ub tots! $20.00 <br /> rocess fee <br /> otal - $269.50 <br /> 1 <br /> i <br /> F <br /> j41 <br /> I <br /> l <br />