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gj q <br /> 6c � ni �8 Ra* is rt dR 8� <br /> t '�A <br /> NnRa 1 f <br /> iL1ro..n`?`> "`"i.'. <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 15569 <br /> PLEASE MU4T AND Pt Bsm HARD' MobaLmos HJIFMXE W LL NOT OR ACCEpIED. --y <br /> Waste Hauler Company Name (�- 7hicle capacity q U 1 <br /> Vehicle License No. � A-- <br /> Y � Load t <br /> Complete naive, address, type, and quantity of wa a 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 fords. Random verification <br /> will be made by sRWcp. <br /> 1. Name: <br /> Address: - \ { <br /> Zip <br /> Phone No. : ( ) <br /> Waste Type: Quantity: gal. <br /> SignaturIe <br /> Date: I { Tim.s <br /> Within Et ckto city limits? Yer o <br /> ( <br /> Allowable Waste Type; place applicable nualber in apace provided above, <br /> 1. Residential eeptaga 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. special <br /> Disharge <br /> Si UWM rM a be nwdred.be tura•ed a.Wmmbb pw e.n m e bliftd. <br /> A SP.w Pftmb ew:bo c mplo d ed gpk d by laWep bd.ducb.W M g Md. <br /> I, 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's 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, an 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 /> SRWCT regulation, may result in the immediate suspension of my Wastm Hauler Permit an /or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br />