Laserfiche WebLink
10/16/2008 11:39 2094685672 CLEAN HARBORS PAGE 03/05 <br /> San o <br /> Joe vin S <br /> '7850 South Agridgeford StreeermInent HH�✓Ce flection Facility <br /> Stockct",Ca 95206 <br /> Direct:209.468„5670 <br /> Uft <br /> Fax:209.468.5672 <br /> CESQG jIV'VEQRY FO <br /> R_Nl ="*@*hit <br /> Compllny Name: <br /> Address: Contact: <br /> City: - --W <br /> Zip Code: <br /> Phone No,: <br /> *EPA ID#: "- --— <br /> *If you do not have an EPA ID#,you <br /> Event L.ocati0n/Daif( known); mate y call(800)618-6942 to obtain orae, <br /> Type of Waste <br /> Quantity Size and Type Liu To be tilted opt by <br /> Of Container Liquid/ C1eaa Barbar <br /> Solid cosi per T rt I Coat�)�LRteX,PQlt1t Ib,igai, <br /> $gat plrtstec <br /> backel Ligand <br /> Sub Total <br /> Et <br /> You a�mere room please attach another sheet and list as P�essi�r Fee <br /> 1'otai to baid b CE G <br /> �ecilied on this form. <br /> j earthy the bu9iuess that I am r•epreSenting !s a Conditionally Exam <br /> (CESQG)who generates pa more than l00 lallogrpgtB(Zy gallods or 220 Small Qtlanti <br /> per mouth based On arr annual avorug® and the ry Generator <br /> neaidtoum quantity of n an accepted At an time of eprwentative of the CES of t*w rdans waate <br /> dispo=1 am%incurred shall be the mponslblli of the Cdispoaal is 29 g C)k;SQC�,Ponddande�and the <br /> ty ESQG to a aliorea or 220 <br /> pay <br /> ny <br /> the time or disposal. <br /> Signature <br /> Date <br />