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CESQG DATA SHEET & WAIVER <br />.L!. <br />San Joaquin CountyHousehold Hazardous Waste Collection f=acility <br />7850 South R. A Bridgeford Street, Stockton, CA 95206 " <br />Shone: 209-468-3066 Fax. 209-468-3078 <br />Business Information <br />Company Hams (please print) any Representative (priX%-4-�. <br />ur name) <br />om <br />'... CON lZX( C) Tl! ., Comp45 r- <br />Street Address <br />1 UV h.i . 14 a !-,.aj i <br />Citylstateop Code Area Code & Telephone Number <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 e�ss_ffian tt1{5 k'itgrams (ZT gallons or �d7'� azo ous wraste peg moat 13usiriesses that gener�fe m6W- <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 review <br />your annual manifests or consult with the County Environmental Health Department to determine your eligibility for use of this <br />program. Thank you. <br />I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator (CESOG) 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 1, the representative of the CESQG, understand the maximum quantity of waste accepted at the time fo . <br />disposal -is 27 gallons. or 220 pounds and any disposal costs Incurred shall be the resyQisiblitity of the CESOG to <br />pay at the time of disposal. /7 <br />Time Signature <br />DO NOT WRITE BELOW THIS LAVE <br />INVENTORY <br />(To be completed by collection personnel) <br />Item o.. ­A. 36 -6 1r....6 <br />Comments: <br />