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rf �� <br />CESQG DATA SUEET & WAIVER <br />Bu.skless Inform tion <br />Company,Namc <br />lease pril <br />p <br />It) <br />Compan y Representirive (prior your name) <br />strea Address <br />T 4 <br />L <br />A <br />-�.'ity/State/7,i P (.;o <br />6 <br />Telephone Nu niber <br />Total <br />Business Wilver <br />State and fede . ral lazardous waste laws limit the use of this type of waste collection programs to those businesses that <br />generate i_ -ss t 100*Jlo�- <br />m <br />han as (27 gallons or 220 pounds) of hazardous waste per month. Businesses that generate more <br />'than* lfiii <br />t is amount �e requir: law to use a licensed <br />.... , . . ... . : . d by hazardous waste hauler to manifest and transport their 'Waste. <br />17hereflare, in or:4e *to pattic pale in this program, you must sign the following waiver- of liability. We mcrvc the right to <br />review your-annU• I nlanifesi s or consult with the County Envi roll"' ell ta t Health Department to determine:your eligibility <br />for use or this b <br />rot ram.. Th i tk you. <br />I c rtifv.the usiness that I am r <br />-epresenting generates no more. than 100 kilograins. <br />) <br />.(2 gallons r,220 pounds) of hazardous w1ste pet- month based on all annual average. <br />Signatu <br />DO NOT WRJTF BELOW T141S UNE <br />N , I NTORV <br />Vr <br />(To be completed by collection personnel) <br />lteln price 11 of Cont. Gallons Pounds <br />Total <br />