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06.'071'2008 13:08 209468567'2 CLEAN HARBORS <br /> PAGE 02/03 <br /> C `� <br /> n <br /> ka ■Habore. <br /> ENVIRONMENTAL SERVICES° c� <br /> San Joaquin County Permanent HHW Collection Facility _ <br /> 7850 South R.A Brldgefnrd StreetLD) <br /> Direct <br /> Stockton, CA 95206 <br /> Direct : 209-468-5670 <br /> Fax 209-468-5672 <br /> CESQG DATA SHEET &WAIVER <br /> Business Information <br /> Valley Arco Pau! <br /> 16 E Harding Way <br /> Stockton, Ca 95204 209-466-9516 <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 kilgrams(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 wasiver 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 /> prngram. Thank you. <br /> I certify the business that I am representing is a Conditionally Exempt Small 0uantity Generator(CESQG)who generates no <br /> more than 100 kilorams(27 gallons or 220 pounds)of hazardous waste per month based on an annual average and I,the <br /> representative of tt-res CESQG, understand the maximum quantity of waste accepted at the time to disposal is 27 gallons or <br /> 220 pounds and any disposal costs incurred shall be the respongi ity of the CESQG to pay at the time of disposal. <br /> 6/5/2008 6:00 PM Signature <br /> ,% 7 —7 <br /> t <br /> DO NOT WRITE BELOW THISLINE <br /> INVENTORY <br /> (To be completed by collection personnel) <br /> (tern Gallons Pounds #of Cont. Price Total <br /> Flammale Liquid 17.0 145 1 $5.00 85.00 <br /> Flammable Solids Hose' 123 1 1.50 184.50 <br /> Sub total 269.50 <br /> Process fee - $20.00 <br /> Total <br /> - $289.50 <br /> Comments: <br />