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So Co HTWF Petaluma Office 500 Mecham Rd #5 Petaluma, CA 94952 Telephone (707) 795-2025 Fax (707) 795-2071 CESQG INVENTORY FORM Company Name: Contact: Address: City: Zip Code: Phone No.: County: ( ) *EPA ID#: *If you do not have an EPA ID#, you may call (800) 618-6942 or www.dtsc.ca.gov to obtain form 1358. Appointment /Date (if known): Type of Waste (example): Aerosols Quantity 4 Size and Type of Container Liquid/ Solid 5 gal plastic bucket Liquid To be filled out by Clean Harbors Cost per lb./gal. Total Cost Sub Total (Varies upon waste weight) Processing Fee Total to be paid by CESQG (Make check payable to Clean Harbors Environmental) If you need more room please attach another sheet and list as specified on this form. I certify the business that I am representing is a Conditionally Exempt Small Quantity Generator (CESQG) who generates no more than 100 kilograms (27 gallons or 220 pounds) of hazardous waste per month based on an annual average and I, the representative of the CESQG, understand the maximum quantity of waste accepted at the time of disposal is 27 gallons or 220 pounds and any disposal costs incurred shall be the responsibility of the CESQG to pay at the time of disposal. Signature Date G/Forms/HHW-CESQG/CESQG Inventory fORM