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_ ,°+ m <br /> 0 D <br /> ., 1-4 <br /> Q <br /> N N 00 y <br /> N <br /> C O <br /> 3 <br /> 7CD <br /> ,D O <br /> �• .+ Z <br /> O <br /> Son n a <br /> � C <br /> ((D -s Ano, N <br /> � e __--11f1`ll A raj. <br /> 29 <br /> 'rOCK-roMREG <br /> .'c.tiEON <br /> , WASTE NA ASTEWATER CONTROL FE <br /> N <br /> USER MANIFEST FORM CILITY O <br /> > cr,nrri> V ds(e haulePLEA <br /> SEPR BE, BY UJgST 7 <br /> ro.ust ehtole Com AND PRESS E HAULER BEFORE <br /> Lice pdny 1�1RD. INCOMp ENTRY TOW <br /> COmpl Ise No-, Name (�yi_,, Y . -r,�EtE OR ILLEGIBLE FORMS WILL <br /> 3 w4rEr; repr ete namew c Not Eac <br /> Ipadesentativadore— Date Vehicle Capacity 3 i,)'*CC <br /> `TYPE attach ad from each,tYPe, and quantity o --Key# __Load# �-- <br /> ditionw for source,verif waste source(s)below. A signature <br /> ms. Raltdo Ymg the ontypand quantity stated. If more than Is all be obtained from INSTP m verification Will be made by SRWCF. o in the waste <br /> ur sour m a <br /> ❑ r <br /> L3 c <br /> ❑ 3. Name. <br /> Address: <br /> ❑ Phone No. ------ <br /> Wasle Type: E <br /> �Ouanbly: <br /> W Generator Signature --9ai. <br /> Date: —�— <br /> ,lol Time <br /> CU Within Stockton Illy limits" �•,;; <br /> kNo <br /> Allowable Waste Type:Place applicable number in space provided above. In <br /> 1.Residential Set •�•< •-•.� <br /> P age 2 Portable Toilet' 3.Restaurant Grease Interceptor I.Special Discharge'- <br /> 'Signature will not be required.but location and responsible person shall be indicated. <br /> J "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 my knowledge I have accurately <br /> described the type,quantity.and source of all s;'astes 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 sepl.3g„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(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. 1 am aware of the conditions <br /> and requirements of the Waste Hauler Permit Further, I understand that failure to accurately <br /> with my Waste Hauler Permit andior any applicable SRWCF re describe the above <br /> information or failure to complym <br /> immediate suspension atm y 9ulation,may result in the o <br /> y Waste Hauler Permit and/or other penalties as may be allowed by law. Q <br /> Dump Date and TimeLn <br /> Waste Hauler Signature 70 <br /> O <br /> v ODh1AiGRPWISEICOS.hlUO.t, gF69.t RetxE•d 1+15 v <br /> N UD libr; _i9. 00 <br /> N 00 <br /> F� <br /> O n 00 <br />