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i <br />Business Information <br />,NIMBI M." <br />MSE ENVIRONMENTAL <br />A division of Teris <br />Benicia Office <br />3690 Sprig Street, Suite B <br />Benicia, CA 94510 <br />Telephone (707) 747-5589 <br />Company Name (please print) Company Representative (print your name) <br />t),Pr)Pv %,4 11, j 1r. VV r°.1 i <'I t').--, Q(a i` I _ C" ►'t C ( ",- 1%v i r �- <br />City/State/Zip Code Telephone Number <br />L&A't C (D O61) _ - <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 <br />more than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport their <br />waste. Therefore, in order to participate in this program, you must sign the following waiver of liability. We reserve the <br />right to review your annual manifests or consult with the County Environmental Health Department to determine your <br />eligibility for use of this program. Thank you. <br />I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator (CESQG) who <br />generates no more than 100 kilograms (27 gallons or 220 pounds) of hazardous waste per month based on an annual <br />average and I, the representative of the CESQG, understand the maximum quantity of waste accepted at the time of <br />disposal is 27 gallons or 220 pounds and any disposal costs incurred shall be the responsibility of the CESQG to pay at <br />the time of disposal. <br />)ate Time Signature <br />e : i L <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 />Comments: <br />G:\Forms\HHW-CESQGWorthern CA CESQG forms\CESQG data sheet & waiver -Benicia Office.xls <br />