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CESQG DATA SHEET,& WAIVER <br /> Business Information <br /> Company Name(please print) Company Representative(print your name) <br /> Street Address <br /> City/State/Zip Code Telephone Number <br /> Business Waiver <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 kilograms (27 gallons or 220 pounds) of hazardous waste per month. Businesses that generate <br /> more 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 following waiver of liability. We reserve the right to <br /> review your annual manifests or consult with the County Environmental Health Department to determine your eligibility <br /> for use of this program.Thank you. <br /> I certify the business that I am representing generates no more than 100 kilograms(27 <br /> gallons or 220 pounds)of hazardous waste per month based on an annual average. <br /> Date ¢ Time Signature �; 1 <br /> _ . <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Item Price #of Cont. Gallons Pounds Total <br /> Total <br /> Comments: Y "i V x'41 99 p <br />