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i <br /> STOCKTON REGIONAL WASTEWATER CONTROL FACILI'T'Y <br /> WASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF, 4 7 7 7 <br /> PLEASE PRINT AND PRE A1�D. INC} PL TE OR ILLEGIBLE FORMS WILL NOT BE ACCEaED. a <br /> Waste Hauler Company Name U J i C e-r, Vehicle Capacity J��U <br /> Vehicle License No.Z/� y "2 Date Key# Load# <br /> I 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 additional forms. Random verification will be made by SRWCF. <br /> I <br /> 1. Name: � ���i�1 'n ��CaS 2. Name. r,10,* <br /> Address: /„X�}/ , ,� Address; 3,�2_0 / W <br /> Zip-cam— ����-� 6��, Zip <br /> TZ/q <br /> I <br /> i Phone No.:(a­,)ci' -t l 0r- Phone No-:_a0 q 9 �$`f ---/tIG <br /> Waste Type:Z 6 T Quantity: eJ4.,C, al. Waste Type:, Quantity:] _gal. v. <br /> Generator Signature: Generator Signature: <br /> Date- /5' �� Time: �• �� A. . P.M. e !2 �� ' /� <br /> l� � Time: 16c, .M P. <br /> j Within Stockton city limits? i No Within Stockton city limits? No <br /> I <br /> I Name: 4. Name: <br /> 1 Address: Address: <br /> Zip Zip <br /> I Phone No.:( ) Phone No.: ( ) <br /> Waste Type: Quantity: gal. Waste Type: Quantity pal. <br /> Generator Signature- Generator Signature: <br /> Date: Time: A.M. P.M. Date: Time: A.M. P.M. <br /> Within Stockton city limits? Yes No Within Stockton city limits? Yes No <br /> TOTAL QUANTITY(ALL Sources); gal, <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 /> 1 <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 perjury, that to the best of_rriy knowledge thave accurately i <br /> 8escribed the type, quantity, and source of all wastes which I now request to dispose of at the SRWCF. I further declare, <br /> ;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 /> !case of a Special Permit, is not hazardous and does not exceed previously authorized limits, as per Pretreatment/Source <br /> -Control requirements_ 1 also declare, under penalty of perjury, that the truck(g)used tgytransport this waste was free of all <br /> (materials character zed by law as a hazardous waste or substance at the time of said use. I am aware of the conditions <br /> land 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, y result in the <br /> I suspension of my Waste Hauler Permit and/or other penalties as may be allowed by law. <br /> EZ <br /> (Date and Time of discharge at SRWCF. <br /> !Waste Hauler Signature AUG 2 .5 <br /> ID15, <br /> 'ODMAICRPWISEICD$.MUD.MUD_Library,i33669-1 EN1 j' <br /> b0/b0 dJdd 21310021 01021 9Z6S59b6aZ tit.b�Q <br />