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i <br /> STOGKTON REGIONAL W STE'W'A CONTROL FACILrFY <br /> WASTE:11AU R » ST F,.RM <br /> 39883 <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. <br /> PLEASE PRINT ANDPRESS HARD. 'N oRny ISLE PORMS WU.L NOT BE ACCPP'rED. <br /> Vehicle Capacity <br /> Waste Hauler Company Name - �' <br /> Vehicle License No. <br /> -7 1 / % Date t-( Key # _Load I <br /> Complete name, address, type, and quantit of wast source(s) below. 1► signature shall be <br /> obtained from a representative from each ource, v rifying the type and quantity stated. <br /> in the waste load; attac additional forms. Random verification <br /> If more than four sources <br /> will be made by SRWCF. <br /> 1. Name: <br /> Address:/, d <br /> zip lJ <br /> Phone No. :`(��� <br /> Waste Type: � <br /> Quantity: <br /> Signature: -- -V" <br /> Date:` Time: lam' P <br /> Within Stockton city limits? Yes No <br /> lalo <br /> , <br /> er in ace provided eIn <br /> Allowable Waste Type: Plaee applicable n ECEIMED <br /> 1. Residential Septage" 2. Portable Toile 's 3. Restaurant Grease In <br /> Disharge <br /> s ��.� .���,�.;sbp—�be" <br /> o ma. MAY 0 7 2014 <br /> A y�W ptsmit must bo wmpLaod sad,vprwed b'SRWCF befao disch►ti <br /> e alty of perjury, that to the beet of my <br /> and source wastes which I <br /> i, the below named waste hauler, declare nder Pqulantity, 'F4�LTH <br /> knowledge I have accurately described the type, under pe tM <br /> now request to dispose of at the SRWCF. furthe declare, <br /> I was personally informed by the owner, owner'a a eRthatrthisuwaete talus <br /> this waste was received or have personal <br /> ern the aselofg /Special Permit, is not hazardous and <br /> residential septage or g used to <br /> r ury, that the truck(s) <br /> does not exceed previously authorized limits, as er Pretreatment/Source control <br /> requirements. I also declare, under penalty of p j law as a hazardous waste <br /> aware of the conditions and requirements of <br /> transport this waste was free of all materials ch acterized y <br /> or substance at the time of said use. I <br /> the waste Hauler Permit. Further, ately describe the <br /> 2 understand that failure to accur <br /> above information or failure to comply <br /> SRWCF regulation, may with my <br /> Waste Hauler Permit and/or any applicable <br /> result in the immediate suspension of my Waste [ uler Permit and/or <br /> other penalties as may be allowed by law. � <br /> Waste Hauler Sigr1ature - <br /> G' <br />