Laserfiche WebLink
Business Information <br />0 i <br />-IEE <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�"', 1� t `it� el i oc;c� Z. <br />Street Ad re_ss <br />_ <br />City/State/Zip Code Telephone Number <br />�• <br />2425:71) 1 <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 />DO NOT WRITE BELOW THIS LINE <br />INVENTORY <br />(To be completed by collection personnel) <br />(3nllnnc Pntrrtrlc # of Cont. Price Total <br />Comments: <br />G:\Forms\1iHW-CESQGWorthern CA CESQG forms\CESQG data sheet & waiver -Benicia Office.xis <br />_06 *1761 <br />..0�EMWZA+► <br />Comments: <br />G:\Forms\1iHW-CESQGWorthern CA CESQG forms\CESQG data sheet & waiver -Benicia Office.xis <br />