Laserfiche WebLink
01!12/2014 13:56 2094655926 <br /> ROTO ROOTER PAGE 03/03 <br /> i <br /> I <br /> I STOCKTON REGIONAL WASTEWATER CONTROL FACILITY 2 Sol <br /> Lt 0 <br /> i <br /> WASTE HAULER MANIFEST FORM <br /> t <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 48109 <br /> PLEASE PRINT AND PRESS WCC) ET OR ILLEGIBLE FORMS WILL NOT BE ACC_EP,TE�• <br /> o Vehicle Capacity <br /> j Waste Hauler Company Name Load# <br /> i Vehicle License No. <br /> Date Key# <br /> Complete name, address, type, and quantity of waste source(s) below. A signature shall be obtained from a <br /> representative from each source, verifying the type and quantity stated; If more than four sources In the waste <br /> load; attach ditionaI form Random verification will be made by SRWCF. <br /> �� 2. Name: <br /> E1. Name: ��-� <br /> Address: <br /> Address: <br /> I Phone No_: <br /> Phone No.:(200 <br /> � Quanti <br /> Waste Type: 3 Quantity: gal. <br /> gal. Waste Type: ` �° tY <br /> { ® Generator Signature: 4-- <br /> Generator ignat re //�/ M M <br /> Date: Time: .7� A Date: \- 1 - 1 "� Time: <br /> Within tockton city limits? es No Within Stockton city limits? Yes a� <br /> 4. Name: <br /> 3. Name: <br /> Address: <br /> Address: <br /> Z <br /> i Zip ip <br /> ( ) <br /> Phone No.:( Phone No.:) <br /> Waste Type: Quantity: clal. Waste Type: Quantity: gal. <br /> Generator Signature: Generator Signature: <br /> Date: <br /> Time: A.M. P.M. Date: Time: A.M.P.M. <br /> Within Stockton city limits? Yes No Within Stockton city limits? Ye �j o <br /> TOTAL QUANTITY(ALL Sources): ./ I• <br /> i <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. Special Discharge— <br /> "Signature will not be required,but location and responsible person shall be indicated. <br /> �'"A Special Permit must be completed and approved by SRWCF before discharge is allowed. <br /> I, the below named waste hauler, declare under penalty of pedury, that to the best of my knowledge I have accurately <br /> described the type, quantity, and source of all wastes which I now request to dispose of at the SRWCF. I further declare, <br /> j under penalty of perjury, that 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 residential septage or grease, or in the <br /> I case of a Special Permit,is not hazardous and does not exceed previously authorized limits, as per Pretreatment/Source <br /> E Control requirements. I also declare, under penalty of perjury, that the truck(s)used to transport this waste was free of all <br /> materials characterized by law as a hazardous waste or substance at the time of said use. I am aware of the conditions <br /> and requirements of the Waste Hauler Permit. Further, I understand that failure to accurately describe the above <br /> `information or failure to comply with my Waste Hauler Permit and/or any applicable SRWCF regulation, may result in the <br /> immediate suspension of <br /> my Waste Hauler PermV and/or other penalties as may be allowed by law. <br /> 1Date ,� I and Time 1 of discharge at SRWCF. r <br /> I Waste Hauler Signature l <br /> k0DMAIGRPWISEICOS.Mr tO: _Library:133669.1 �/ Y <br /> ' AUG 2 5 2015 <br /> ENVIRON.MFNTAr <br />