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leaHarbor <br /> RECEIVED �f <br /> ENVIRONMENTAL SER YIC ST JUL <br /> 18 2011 <br /> San Joaquin County Permanent H W Collection <br /> Facility <br /> c MEN7P.L HEALTH <br /> 7850 South R.A Bridgeford Street PERMIT/SERVICES <br /> Stockton, CA 95206 <br /> Direct: 209-468-5670 <br /> Fax: 209-468-5672 <br /> CESQG DATA SHEET & WAIVER <br /> Business Information <br /> ,I fC-A <br /> LIS <br /> f <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 kilgr$ms(27 gallons or 220 pounds)of hazardous waste per month. Businesses that generate more <br /> than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport their waste. <br /> Therefore, in order to participate in this program,you must sign the following wasiver of liability.We reserve the right to review <br /> your annual manifests or consult with the County Environmental Health Department to determine your eligibility for use of this <br /> program. Thank you. <br /> I certify the business that i aFn representing is a Conditionally Exempt Small Quantity Generator(CESQG)who generates no - <br /> more than 100 kilorams(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and I,the <br /> representative of the CESQG$,understand the maximum quantity of waste accepted at the time fo disposal is 27 gallons or <br /> 220 pounds and any disposal costs incurred shall be the responsiblitity of the CESQG to pay at the time of disposal. <br /> 6/5/2008 Signature <br /> DO NOT WRITE BELOW THIS LINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> Item Gallons Pounds #of Cont. Price Total <br /> Fuel Filter 2 2 $1.00 2.00 <br /> Flammable Solid 17 1 1.50 25.50 <br /> Sub total 27.50 <br /> Process fee - $20.00 <br /> Total - $47.50 <br />