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L:Yf 4 <br /> R S (yyR G <br /> r' M�f�l � (Y �f'�R?P5�WRiYR OS A40 4:.SD%e \k R1 . L 9vfj`Ai��: k s �4aa 5 <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 15568 <br /> PIZASH PWR9'AND"EM HARD. v000N"M OR g.1EMU POR1a1 W113.210T 9E I ACCHRPD. <br /> � <br /> Waste Hauler company Name '- � 5 -''.d' 'Zvehicls capacity I \ <br /> Vehicle License No. _, ( i �.. -,�-� .�iDate i 2 U -4cey 0 Load / <br /> Complete naw, address, type, and Quantity of waste source(s) 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. Random verification <br /> will be made by S1NCP. <br /> 2. Nave �, � �" <br /> Address: I 1 ✓� <br /> Zip <br /> Phone No. s ( ) u — <br /> Waste Types ant ys ()�J gal. <br /> ,_Siiinatur�ociTy�sli�m'ita? <br /> n \ _�... .] <br /> Data: <br /> 5 A.N. P.m- <br /> Within Stag <br /> 1 <br /> Allowable Waste 'Types Place applicable number in space provided above. <br /> 1. Residential Septago 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. special <br /> Dishargs <br /> 9ipo.aua vat m be nwsi,ed,b,d be ad,e.p=WW pe.m,b.a bd adioeea. <br /> A SpcW rww aua be 0OW& d wA wpL cd by SRWC P bdm 4"bum,r sawed. <br /> 1, the below named waste hauler, declare under penalty of perjury, that to the best of my <br /> knowledge I have accurately described the type, quantity, and source of all wastes which i <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, owner'e 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(s) 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 Permit. 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, <br /> Waste Hauler Signature .. ,��s A <br />