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STOCKTON REGIONAL WASTEWATER CONTROL F <br /> ACILI ry ka F. D <br /> WASTE HAULER MA (FEST FORM MAY 0 7 <br /> 2014 <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TOSENCARONMEN7 �HE7ALTH <br /> PLEASE PRINT AND PRESS HARD. INCOMPLETE OR ILLEGIBLE FORMS WILL NOT BEAAT <br /> Vehicle Capacity MENT <br /> Waste Hauler Company Name <br /> Vehicle License No. - - <br /> Date Key# Load# <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 additional forms. Random verification will be mad a by SRWCF. <br /> 1. Name: S r1, S L"f -t , J Z <br /> Address: r �T <br /> zip <br /> Phone No.:(:­)'i 4-20 <br /> Waste Type: 1 - ' r Quantity:__ 9 <br /> Generator Signature: "-- <br /> Date: Time: .M'. P.M. <br /> Within Stockton city limits? Y S No <br /> Allowable Waste Type: Place applicable number in space provi led above. <br /> 1. Residential Septage 2. Portable Toilet' 3. Restaurant G ase 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 di charge is allowed. <br /> I, the below named waste hauler, declare under penalty of perjury, 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 /> 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 was contains only residential septage or grease, or in the <br /> ce <br /> case of a Special Permit, is not hazardous and does not exceed p viously authorized limits, rt per wastPretre wasfr Sof all <br /> Control requirements. I also declare, under penalty of perjury, that he 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 unde stand that failure to accurately describe the above <br /> information or failure to comply with my Waste Hauler Permit and/c r any applicable SRWCF regulation, may result in the <br /> immediate suspension of my Waste Hauler Permit and/or other pen ilties as may be allowed by law. <br /> Date and Time of discharge at SRWCF. <br /> Waste Hauler Signature ___7 <br /> ::ODMAIGRPWISEICOS.MUD MUD_Library:133669.1 <br />