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CESQG DATA SHEET & WAIVER <br /> San Joaquin CountyHousehold Hazardous 1Naste Collection Facility r' <br /> 7850 South R.A Bddgeford Street, Stockton, CA 95206 '° .4 <br /> Phone: 209-4(38-3066 Fax:209-4CA-3078 : <br /> -Business Inforrnallon <br /> Comy�nv Nornn <br /> o Ica lint -- -...W,.._ <br /> , tf' N �) Company F7e art®11V6(print j10ut name} <br /> t..< t fr — f:Lc�.c J�}.,a.-, <br /> Street Address <br /> CitylStatW_ip Code Area Code 6 Telephone Number <br /> I L„-A , C.t— S �-�-+to _o I I,-r -Is ub <br /> P A c_,q���C.S 3 S <br /> Business Waiver �A7 <br /> State and federal hazardous,waste laws limit the use of this type of waste collection programs to those businesses that <br /> generate less than 100 kilgrams(27 gallons or 220 pounds)of hazardous waste per month. Businesses that generate more <br /> than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport their waste. <br /> Therefore,in order to participate in this program. you must sign the fallowing waivpr of liahitity Wra ro.gorva the right to rnvipw <br /> your annual manifests or consult with the County Environmental Health department to determine your eligibility for use of this <br /> prvyrarn. th�uk yvu. <br /> I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator(CESQG)who <br /> generates no more than 100 kilograms(27 gallons or 220 pounds)of hazardous waste per month based on an annual <br /> average and I,the representative of the CESQG. understand thn mavimrrm nnantity nt waRtn—ar0nrr at Olin time On <br /> disposal is 27 gallons or 220 pounds and any disposal costs incurred shall be the responsiblitity of the CESQG to <br /> pay at the time of disposal, <br /> Data Time —-- ` n tU <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To he cornpie(ed by collectxm poirrinnel) <br /> Item gallons Pound; 4 of r;ont Prica Total <br /> U777Za ,� <br /> 61 <br /> %t r �, l�.l, << , ,f -3 cz <br /> Total <br /> Comments: <br />