I hereby certify that the business listed below meets the criteria to qualify as a Conditionally Exempt Small Quantity Generator (CESQG) and that the business may only participate in the City of Flagstaff's voluntary Small Business Waste Program at the HPC so long as it qualifies as a CESQG. Additionally, I hereby declare that the contents of the waste consignments agreed upon shall be fully and accurately described by proper shipping name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable regulation of the Department of Transportation (DOT).

I have also reviewed and understand that there are costs associated with my business waste disposal. I understand that any adjustments and final billing will be determined at my appointment or upon completion of processing all waste. Finally, a copy of this document and any supporting paperwork will be kept in the generating CESQG files for regulatory review and hazardous compliance monitoring for a minimum of 3 years.

Generator Name (Name of Business):*

Contact Person (Name):*

Contact/Telephone #:*

Contact Email:*

Physical Location:*

Attention:

City:*

State:*

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Zip Code:*

Date of Application:*

Mailing/Billing Address (1):
Same as Physical Location?

Yes, If yes please skip alternate address

No, If no please provide alternate address

Alternate/Mailing/Billing Address (2):

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:

Alternate/Emergency Contact Person:*

Alternate/Emergency Phone Number:*

If in the event an emergency occurs before or during your appointment, or your business is not timely for their appointment due to an unforeseen circumstance, an alternate/emergency contact person and phone number are required for immediate assistance or verification.

By electronically submitting this form, I certify that I have the authority to make these statements on behalf of my business, organization and/or firm and to the best of my knowledge the statements made and or information given is true and accurate.