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Cl <br />Company Name (please print) Company Representative (print your name) <br />13 C e rJ 440 611, lir C C j> 1 � r.f �'1 t` U G !�d (, C a Y N� 7- Q bt S, <br />Street Address p J I t 4^ <br />_57 <br />City/State/Zip Code Telephone Number <br />o V1. C,: A (Zo 9 ) S6 -7 - /0 5, <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 kilograms (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 waiver of liability. We reserve the right to <br />review your annual manifests or consult with the County Environmental Health Department to determine your eligibility <br />for use of this program. Thank you. <br />I certify the business that I am representing generates no more than 100 kilograms <br />(27 gallons or 220 pounds) of hazardous waste per month based on an annual average. <br />Date Time Signatur <br />z o t .�' • 5/0 <br />DO NOT WRITE BELOW THIS LINE <br />INVENTORY <br />(To be completed by collection personnel) <br />Item Price # of Cont. Gallons Pounds Total <br />E1,1 n <br />Total <br />Comments: <br />