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_ B7/11/2007 10: 0 • 209468 72 CLEAN HARBORS _PAGE_ 01101 <br /> L SIE; <br /> SO Joaquin County Permanent HHW Ce,ftection Facility <br /> 7850 South RA Bridgeford Street <br /> Stockton,Ca 95206 <br /> Direct:209-468-5610 <br /> GESQG INVENTORY672 FO <br /> RM <br /> Company Name: J <br /> Address: Contact: <br /> City: L <br /> Zip Code: <br /> County: 9 Phone No.; <br /> *EFA.IIS#: <br /> *If you do not have an EPA ID#, you may call (804)618-6942 to obtain Event L,ocatiozr/Date (ifknown): n one. <br /> �Type of Waste To be fill <br /> Quantity Size and TYpe Liquid/ <br /> Of Container Clean Harbor <br /> Solid Cost per Total Cost <br /> (example):Latex Falnt !b./gal. <br /> S gal plastic Liquid <br /> bucket <br /> rt►(? <br /> rz. . <br /> n-KAn ® r <br /> ® ' <br /> Ri0 <br /> el <br /> e? _ <br /> a <br /> SLuk Total <br /> Fracessirt Fee <br /> It you need more room please attach arrather sheet and list as speerd on thissform.Paidb CESOG <br /> I<certify the business that f amt representing is a Conditionally Exempt Small Qerantity Generator <br /> (CESM Who generates no more than 104 kilograms(27 gallons or 220 pounds) of ha;mrdous waste <br /> per month based on an annual average and I, the representative of the, CESQG, understand the <br /> maximum quantity of waste accepted at the time of disposal is 27 gallons or 220 <br /> Pounds disposal tts in d shall responsibility of the CESQG to pay at the time c)f disposal. any <br /> Sig1katu <br /> I7►t:te <br />