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11/13/2008 14:49 2093312012 SJC PARKS PAGE 10/14 <br /> UL--AN HAHLJURS <br /> wpm <br /> M <br /> San Joaqulq COUrtty tsertnanant HHW Ce'llectia <br /> 7854 South RA gndaet'ord Street n Facility <br /> StocktOn,Ca 95206 <br /> direct;209-468-5610 <br /> Fax:209-46&S6?a <br /> ES zNV NTORY FORM <br /> c'DmPallY Name: 5a <br /> Address: / 310ti,Contact: <br /> City: Loa <br /> Zip Cuda: S Phone No., <br /> County: '5'! <br /> *EPA ZD#: <br /> *If you do not have an EPA ID#,you may <br /> Event Location/pate(if known); y call (800) 6I 9.69 -2 to obtalti one. <br /> ,,r,ype of Waste out by Quant" �e DOWDOWtY Size and Type Liquid/ T <br /> of ContainerClean gArbor <br /> Solid Cost per Total Cost <br /> (Cmm.Fk)e Latex Point Ib.lgal. <br /> 4 S gut plastic ,l,,tquro id <br /> bucker <br /> v1 �` <br /> Sub Total <br /> Prosessin Free <br /> 11 you need MOM room please attach anotE*ot-Sheet and list as speer eclon thiI to s form, <br /> aid b C'ES�G <br /> t certify the business that x am "Preaenting is a Conditionally l;xerxtpt Small Qerantitp GeneN•s►tor <br /> {G`ESQG}Who generates no more than 100 icilogratces(Z7 gallons at m pounds) of ltat►.Ardott�wesxe <br /> per mtoptb based as an annutli Average and I, tits rcpresetttatsvre of the and <br /> rmaximnert 9ttaatity of waste accepted at the time of disposal is 2T gallons or 220 pounds and tiny <br /> disl►osW is In ed shall responrstibflity of the CESQG to pay At fire timCESe <br /> eatacterstaad the <br /> xne of disposal. <br /> Date <br />