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f. <br /> .......... <br /> .. <br /> Mtn <br /> A <br /> TO BE COMPLETED BY. WASTE HAULER BEFORE ENTRY TO SRWCF. 11783 <br /> PLFAS$PWTr-AND.PRFSS BARD. 1NCUldP zm oit nxw LB FoRAo WII.L Nar BE Accmi Fes. .' <br /> Waste Hauler Company Nasse w . E�Vehicle .Capacity_ [� ; <br /> Vehicle License No. Date Key # Load # <br /> complete name, address, type, and quantity of waste soukee(s) below. A signature shall be <br /> obtained from a -representative from each source,' verifying the type and quantity stated. <br /> If more than four sources in the .wasta .load; attach additional' forms. Random verification. <br /> will be wade by SRWCF. <br /> 1. Name: 0 <br /> �{' , :A r <br /> Address:--_ �;fi r 4.r. :y_ <br /> a zip i <br /> Phone No. : ( ) <br /> Waste_Type: Quantity: g .2 Q: al. <br /> Signature: W <br /> Date: r mime: - A.I4. <br /> Within Stockton city limits? Yes No <br /> s <br /> 1. f <br /> Allowable waste Type: -Place applicable number in space provided above. <br /> 1. Residential Septage' 2. Portable Toilet`. 3. Restaurant Grease Interceptor 4. Special <br /> Disharge— <br /> Sgpft es will not be regmmd,but l=bm and mpaaaible person slue be mdumd. <br /> A Special P muat be cmvieW k and Wpwwcd by SRWCF bdare dia&mp a&G wW. <br /> I, the below named waste hauler, declare under penalty of perjury, .that to the best of my <br /> knowledge I have accurately described the type, quantity, and source of all wastes which I <br /> now request to dispose of at the SRWCF. I further declare, under penalty of perjury, that <br /> 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 <br /> .residential eeptage or grease, or in the case of a Special Permit, is not hazardous and <br /> does not exceed previously authorized limits, as per Pretreatment/Source Control <br /> requirements. I also declare, under penalty of perjury; that the truck(s) used -to <br /> transport this waste, was free of all materials characterized bylaw as a hazardous waste <br /> or substance at the time of said use. I amaware of the conditions and requirements of <br /> the Waste Hauler Permit. Further, I understand .that failure to accurately describe the <br /> above information or failure to comply with my Waste Hasher Permit and/or any applicable <br /> SRWCF regulation, may result in the immediate suspension of sty Waste Hauler Permit and/or <br /> other penalties. as may be allowed by law. <br /> Waste Hauler Signature��-�` <br />