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RECEIVE 2-1�;' 1 1, MAY 0 7 201 �� I j STOCKTON R� 1� kL NTROL FACILITY i AST FEST FORM TO BE COMPLETED BY WASTE HAULS I BEFORE ENTRY TO SRWCF. 417 17 7 PLEASE PRINT AND PRE D. INC PL TE DRI EGIBLE FORMS WILL NOT BE ACCEPTED. Waste Hauler Company Neme U l C Vehicle Capacity 0 Vehicle License No. 7_ Date <ey# Load# I Complete name, address, type, and quantity of waste source(s) below. A signature shall be obtained from a j representative from each source, verifying the type and qua tity stated. If more than four sources In the waste load;attach additional forms. Randomverificationwill be rna a by SRWCF. - 1. Name: SR.1 � � L Gi �t'�) XPrGss Name: _,Cl2SGL lr�lOd le- Address- „ t n 1r^a ddress: �� tN Q w� aw✓�N� l zip6�1 •Zip 5,�z14 I i PhoneX00 Fhone No-:J20$ Waste Type:1 PJ/ 42 -f Quantity: C�� al, rite Type: Quantity:/� gal. i Generator Signature: CL 0-- enerator Signature. Date:f� '!� �L Time: �• �J A. . P.M. e: !2—�-'S' �� Time: 60 M P. Within Stockton city limits? No Within Stockton city limits? No I I 3. Name: ;dress: ' Name: I Address: 1 zip I Zip IP one No.:( ) I Phare No.:{ ) Waste Type: Quantity: gal. Waste Type: Quantity: pal. Generator Signature: Generator Signature: Date: Time: A-M.P.M. Date: Time: A.M. P.M. !Within Stockton city limits? Yes No Within Stockton city limits? Yes No 1r TOTAL QUANTITY(ALL Sources): gal. !Allowable Waste Type: Place applicable number in space pro ded above. j,1.Residential Septage 2. Portable Toilet` 3. Restaurant Grease Interceptor 4.Special Discharge" Sgnature will not be required,but location and responsible person shall b indicated. ':`A Special Permit must be completed and approved by SRWCF before discharge is allowed. I, the below named waste hauler, declare under penalty of pequ , that to the best nf-my knowledge r have accurately described the type, quantity, and source of all wastes which I now request to dispose of at the SRWCF. I further declare, 'under penalty of perjury, that I was personally informed by the owr ier, owners agent, or occupants of the property where 'this waste was received or have personal knowledge, that this was a contains only residential septage or grease,or in the ]case of a Special Permit, is not hazardous and does not exceed pi eviously authorized limits,as per Pratreatment/Source Control requirements. I also declare, under penalty of perjury,that the truck(s)used t%transport this waste was free of all Imaterials characterized by law as a hazardous waste or substanci at the time of said use. I am aware of the conditions !and requirements of the Waste Hauler Permit. Further, I understand that failure to accurately describe the above Hnformation or failure to comply with my Waste Hauler Permit and/i ir any applicable SRWCF regulation, may result in the iimmediate suspension of my Waste Hauler Permit and/or other pen 31ties as may be allowecT by law. 1 0 (Date and Time of discharge at SRWCF. Nvaste Hauler Signature .ODMAIGRPWISMC69,MUD.MUD_l.ibraryt 33669.1 b01b0 39dd d310021 01021 9Z6999b60Z 11:p1 Z10Z/Li/7-1