Fillable Form 3.: QUESTIONNAIRE VSQG 1. 2. VERY SMALL (Sonoma County Waste Management Agency)

Fill Online, Printable, Fillable, Blank Form 3.: QUESTIONNAIRE VSQG 1. 2. VERY SMALL (Sonoma County Waste Management Agency) Form

Use Fill to complete blank online SONOMA COUNTY WASTE MANAGEMENT AGENCY (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 3.: QUESTIONNAIRE VSQG 1. 2. VERY SMALL (Sonoma County Waste Management Agency)

On average this form takes 40 minutes to complete

The Form 3.: QUESTIONNAIRE VSQG 1. 2. VERY SMALL (Sonoma County Waste Management Agency) form is 3 pages long and contains:

  • 0 signatures
  • 1 check-box
  • 158 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Sonoma County Waste Management Agency

BROWSE SONOMA COUNTY WASTE MANAGEMENT AGENCY (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
QUESTIONNAIRE VSQG
VERY SMALL QUANTITY GENERATOR (VSQG) HAZARDOUS WASTE
Please provide the following and return by email toxicsdisposal@cleanharbors.com or fax (707) 795-2071 to
Clean Harbors.
1.
QUESTIONNAIRE
2.
A COPY OF YOUR
INVENTORY FORM
(This page)
(EPA ID # may be required)
3.
BUSINESS LICENSE
Upon receipt, Clean Harbors staff will evaluate your eligibility for participation in the VSQG program and assign cost per
pound of material for disposal based on your VSQG Inventory Form. This form will be returned to you via email or fax with cost
information, and an appointment date/time for future dropoff. Complete the Invoice Authorization Form after you receive cost
information. FOR THE SAFET Y OF CLEAN HARBORS STAFF DUE TO COVID -19, PAYMENT BY CREDIT CARD IS REQUIRED.
Listed below are the VSQG Guidelines per California Code of Regulations; 40 CFR 261.5. Please check the box that applies to your
small business:
1. Does your business generate more than 100 kg/220 lbs. of RCRA & Non-RCRA Hazardous Waste in a
YES NO
month?
2. Do you accumulate hazardous waste on site? YES NO
If yes, how much is currently stored?
Location of hazardous waste generation:
Address: City: Zip:
HAZARDOUS WASTE HAULER INFORMATION
Hauler name Type Quantity per month
State and federal hazardous waste laws limit the use of this type of hazardous waste collection program to those businesses
that generate less than 100 kilograms (27 gallons or 220 pounds) of hazardous waste per month. Businesses that generate
more than this amount are required by law to use a licensed hazardous waste hauler to manifest and transport their waste.
Therefore, in order to participate in this program, you must sign this document claiming that you are a Very Small Quantity
Generator. We reserve the right to review your annual manifests or consult with the County Environmental Health Department
to determine your eligibility for use of this program.
500 MECHAM ROAD, BUILDING #5 | PETALUMA, CALIFORNIA 94952 | T. (707) 795-2025 | F. (707) 795-2071 | PETALUMA APOLLO SITE
INVENTORY FORM VSQG
VERY SMALL QUANTITY GENERATOR (VSQG) HAZARDOUS WASTE
JOB #
APPOINTMENT
To be completed by Clean Harbors
Date Time
VSQG INFORMATION
Organization name: Contact:
Mailing address:
City: State: Zip:
County: Phone: Email:
Fax:
Account number (if applicable):
EPA ID number:
*
*
If you do not have an EPA ID#, you may call (800) 618-6942 or visit www.dtsc.ca.gov to obtain form 1358.
COST INFORMATION
WASTE INVENTORY
Please complete fields identifying the types of waste. Do not complete cost information.
To be completed by Clean Harbors
Size and
Liquid Cost per
Type of waste Quantity
Total cost
type of container
or solid lb. /gal.
(example): Aerosols 4 5 gal plastic bucket Liquid
Subtotal (varies upon waste weight
Processing fee
Total to be paid by VSQG
I certify the business that I am representing is a Very Small Quantity Generator (VSQG) 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 VSQG, 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 VSQG to pay at the
time of disposal.
First and last name of responsible party: Date:
RETUR
N COMPLETED FORM TO CLEAN HARBORS
Return this form using the button on the right or email to toxicsdisposal@cleanharbors.com or fax (707) 795-2071
500 MECHAM ROAD, BUILDING #5 | PETALUMA, CALIFORNIA 94952 | T. (707) 795-2025 | F. (707) 795-2071 | PETALUMA APOLLO SITE
4
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
--Select--
$ 0.00
$ 0.00
$ 0.00
RESET
PRINT
EMAIL
INVOICE AUTHORIZATION FORM VSQG
VERY SMALL QUANTITY GENERATOR (VSQG) HAZARDOUS WASTE
JOB #
APPOINTMENT
To be completed by Clean Harbors
Date Time
VSQG INFORMATION
Organization name: Contact name:
Mailing address: City: State: Zip:
Phone: Fax: Email:
SUMMARY FOR PAYMENT AUTHORIZATION
PAYMENT INFORMATION
Invoice number: Date: Amount:
CHECK
INVOICE
Select type:
CREDIT CARD
Numbers:
Expiration date: Security code:
Use information above for credit card billing
Name on credit card:
Total charges to be applied
Organization name:
Billing address:
Billing city Billing state Billing zip
F OR T
HE SAFET Y OF CLEAN HARBORS STAFF DUE TO
COVID -19, PAYMENT BY CREDIT CARD IS REQUIRED.
AMOUNT
RETURN COMPLETED FORM TO CLEAN HARBORS
Return this form using the button on the right or email to toxicsdisposal@cleanharbors.com or fax (707) 795-2071
500 MECHAM ROAD, BUILDING #5 | PETALUMA, CALIFORNIA 94952 | T. (707) 795-2025 | F. (707) 795-2071 | PETALUMA APOLLO SITE
$ 0.00
$ 0.00
RESET
PRINT
EMAIL
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 3.: QUESTIONNAIRE VSQG 1. 2. VERY SMALL (Sonoma County Waste Management Agency)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document