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a4a2- !i11m1111 <br /> �sygq! a ow o s.n 'a., a. ¢. <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 15568 <br /> PUAam MINT AND PMW HARD. V4C0 WMX Om pAaMa P0nM Wal NOT am ACCEPTED. <br /> waste Hauler company Name 4".. -;� ; Vehicle capacity <br /> vehicle License No. -1 1��-�'y Dats ( z y # Load # <br /> Complete name, address, type, and quantity o waste sources) below. A signature shall be <br /> obtained from a representative from each source, verifying the type and quantity stated. <br /> If more than four sources in the waste load; attach additional forms. pandom verification <br /> will be rade by 5RWcr. <br /> z. Name: <br /> Address% <br /> Phone No. t ( <br /> wasteType want y: 4q 06 gal. <br /> �S�ynature: <br /> Dater Z� Time: r ., h,M)- P.N. <br /> Within st'ockt'oA city limit., ss "fro` <br /> Allowable Waste Types Place applicable number in space provided above. <br /> I- Residential Septagi 2_ Portable Toilet' 3. Restaurant Grease Interceptor 4. special <br /> Disharge- <br /> sa,..M ma be .q,.,d,b,la-A-.1d re.poo,els prows,b.a b•.akrna. <br /> A sp.W Form mus be ca Wkud sod.pp cd by SRWCF bdM tidwe Y AHwcd <br /> I, the below named waste hauler, declare under penalty of perjury, that to the bo■t of my <br /> knowledge I have accurately described the type, quantity, and source of all wastes which <br /> now request to dispose of at the SRWCF. I further declare, under penalty of perjury, that <br /> I was personally informed by the owner, owners agent, or occupants of the property where <br /> this waste was received or have personal knowledge, that this waste contains only <br /> residential septage or grease, or in the case of a Special Permit, is not hazardous and <br /> does not exceed previously authorized limits, as per Pretreatment/Source Control <br /> requirements. I also declare, under penalty of perjury, that the truck(*) used to <br /> transport this waste was free of all materials characterized by law as a hazardous waste <br /> or substance at the time of said use. I am aware of the conditions and requirements of <br /> the Waste Hauler Permits Further, I understand that failure to accurately describe the <br /> above information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> SRWCF regulation, may result in the immediate suspension of my Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. �1 <br /> Warta Hauler Signature <br />