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"a„�"a;y. .�"n � u s• "x`> x Y w+ . P s.r„<,m.. P a P m�•tR� 0.7%e:LP s <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 15 5 6 8 <br /> x <br /> PoA pieom[11 POR1m WR1 NOT BE ACCEn E), <br /> {P1 AP PRIIli AND PRH88 wRv. pgOlVi8IH \ <br /> Waste Hauler CamPa Y n Name " ' --'�. 1VehLcle <br /> c <br /> vehicle License No. '"i (� 1;:{�-,�-� Date (C V ey / Load / <br /> Complete name, address, type, and Quantity o waste source(s) below. A signature shall ba <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. tandom verification <br /> will be made by dRWCF. <br /> 2. Names <br /> r <br /> Address: (71 v <br /> Iyip C� <br /> Phone No. ; ( 1 y — <br /> Waste Typesquent y: )v gal. <br /> i4natures r) \ <br /> Data% " Timm. 71.N. P.N. <br /> Within 3t ekto city limits? -y—Q—x <br /> Allowable Waste Types Place applicable number in space provided above. <br /> 1. Residential Septage* 2. Portable Toilet' 3. Restaurant Crease Interceptor 4. Special <br /> Disharge- <br /> SipoeWce,wL as be FuquxW.but b,e and mymmbb peem dwil be wdr wd. <br /> A Sp=W Puma o be o Wie"sod ypl od by SRWCF WW dieobw{e M diMed. <br /> I, the below named waste hauler, declare under penalty of perjury, that to the beat of m} <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, thy,. <br /> I was personally informed by the owner, owner's agent, or occupants of the property whar., <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. 1 A <br /> Waste Hauler Signature �/ .- h -`��'� I•�/ <br /> c t <br />