Laserfiche WebLink
D1/12/2014 13:56 2094655926 <br /> ROTO ROOTER PAGE 03/03 <br /> t <br /> 1 <br /> -q�463 <br /> STOCKTON REGIONAL WASTEW ER CONTROL FACILITY <br /> WASTE HAULER MANIFEST FORM 2�P`(0 0 <br /> l TO BE COMPLETED BY WASTE HAU09 <br /> LER BEFORE ENTRY TO SRWCF. 4 81 <br /> PLEASE PRINT AND PRESS D INCO ET OR IL EG(BLE FORMS WILL NOT 63 • <br /> Vehicle Capacity <br /> Waste Hauler Company Name Load# <br /> i Vehicle License No. <br /> Date K y# <br /> Complete name, address, type, and quantity of waste sourc lty stated.be-lowA signature shall be obtained from f more than four sources In the waste <br /> representative from each source, verifying <br /> verification the type on will be ma by SRWCF <br /> qua <br /> load; attach ditional form _ <br /> �4.r5 2- Name: <br /> f 1. Name: A dress: <br /> r <br /> Address: ) /� ''�� Zip - <br /> f Zlp�`= <br /> Phone No.: ( ) '5 <br /> Phone No.:(2019I 3 `7.2, Quantity:��'�aste Type: <br /> Waste Type: Quantity: gal. �. ►•�— <br /> !n� `� >�.1 Generator Signature: <br /> Generator ignat re. Time: <br /> Date: .M- .M. <br /> Time: A.M� D te: 1- �� - 1 "` <br /> es No Within Stockton city limits? `rte <br /> Within tockton city limits? E <br /> i4 Name: <br /> 3. Name: A dress: <br /> Address. Q Zi 2_ ��4 <br /> ZiRr_ <br /> Mone No.: { ) ENTAL EALTH <br /> Phone No.:( ) aste Type: <br /> Waste Type: <br /> Quantity:_Qal DEPARTMENT <br /> C.enerator Signature: <br /> Generator Signature: Time: A.M.P.M. <br /> A.M. P.M. ate: __ <br /> , <br /> Date: Time:_�� _lI <br /> i <br /> No Within Stockton city limits? Ye ? <br /> No <br /> Within Stockton city limits? Yes <br /> moo( <br /> OTAL QUANTITY(ALL Sources): / <br /> Allowable Waste Type: Place applicable number in space pro idea above. <br /> 1. Residential Septage 2. Portable Toilet` 3. Restaurant rease Interceptor 4. Special Discharge" <br /> `Signature will not be required,but location and responsible person shall a indicated. <br /> A Special Permit must be completed and approved by SRWCF before discharge is allowed. <br /> he best of my <br /> owledge <br /> have <br /> ly <br /> I, the below named waste haulersource of alldwastes which Ienalty ofpno request oerjury. that to td dispose of at the nSRWCF.I further declare, <br /> described the type, quantity, and <br /> j e ov ner, owner's agent, or occupants of the property where <br /> under penalty o epperjury,ohhave personal knowlledge,tas personally hat thby hs wa to contains only residential Septage or grease,or n the <br /> this waste was r <br /> ( er Pretreatment/Source <br /> case of a Speciaml also declare,runderous and does not penalty of pejury th I)reviously <br /> he tru authorized <br /> to(imits,as transport this waste was free of all <br /> Control requirements. <br /> tions <br /> materials characterized <br /> of thelaw as a Wasdo <br /> Hauler us asFurther,bI tun erstand that failure to accurately describe the nabove <br /> and requirementsy licable SRWCF regulation, may result in the <br /> information or failure to comply with my Waste Hauler Permit an /or an app' <br /> immediate suspension of m Waste Hauler Perm�t and/or other penalties as maybe allowed bylaw. <br /> ` r and Time f of discharge at SRWCF. <br /> (Date y` <br /> 1 <br /> IWaste Hauler Signature <br /> 1•�ODMA\GRPWISE=S. _Library.133669-1 <br /> 1 <br />