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10/16/2008 11:39 2094685672 CLEAN HARBORS PAGE 04/05 <br /> Orb "A <br /> San Joaquin County Permanent HT-1W Collection Facility <br /> 7850 South RA Bridgeford Street <br /> Stockton,Ca 95206 <br /> Direct:209-468-5670 <br /> Fax:209.468.5672 <br /> CONDITIONALLY EXEMPT SMALL QUANTITY <br /> GENERATOR(CESQG)HAZARDOUS WASTE <br /> COLLECTION QUESTIONNAIRE <br /> Listed below are the CESQG Guidelines per California Code of Regulations; 40 CFR <br /> 261.5. Please check the box that applies to your small business: <br /> I. Does Your business generate more than 100 k9/220 lbs. of Yes Q No CI <br /> RCRA&Non-RCRA Hazardous Waste in a month? <br /> 2. Do you accumulate hazardous waste on site? Yes [1 No <br /> 13 <br /> If yes,how much is currently stored? <br /> Please print address: <br /> 3. Does your business use a regular hazardous waste hauler to <br /> manifest and transport your waste? Yes ® No O <br /> If yes,please print name of hauler,type and quantity of waste you dispose of per month? <br /> State and federal hazardous waste laws limit the use of this type of hazardous waste collection <br /> Program to those businesses that generate less than 100 kilograms(27 gallons or 220 pounds)of <br /> hazardous waste per month. Businesses that generate more than this amount are required by <br /> law m ale a licensed hazardous waste hauler to manifest and transport their waste. Therefore, <br /> In order to participate in this program, you <br /> Conditionally Exempt Small Quanmust sign this document claiming that you are a <br /> tity Generator. We reserve the right to review your annual <br /> manifests or consalt with the County Environmental Realth Department to determine your <br /> eligibility for use of this program. <br /> Please read and sign below. <br /> I e the business <br /> Generateras that I am representing is a Conditionally Exempt Small <br /> or(CESQG)who generates no ore than 100 kilograms (27 gallons or 220 pounds)ity <br /> mQuant <br /> hazardous waste per month based on an annual average and I, the representative of the <br /> CESQG, understand the maximum quantity of waste accepted at the time of disposal is 27 <br /> gallons or 220 pounds and any disposal costs incurred shall be the respo»sibility of the CESQG <br /> to pay at the time of disposal. <br /> Sl ature <br /> OAFftV HW-CWQwcesclo Quadomgim Date <br />