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FROM FAX NO. Jul. 28 2003 11:2eAM P1
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<br /> TO ,BE :COIWLETEID-;.- .Y.WASTE HAULER .BEFORE ENTRY TO..SRWCF. 151
<br /> 49
<br /> :. ._ Pt,»S9 PIM arm PYY.SS 1 URD' n'icoW[,Mox. FORMS VIRL NOT BE aa,-�..
<br /> 'Waste Hauler Company Name capacity Z10
<br /> Vehicle
<br /> vehicle License •No. to Key;# Load #'
<br /> complete name, address, .tyPq.''and quantity f. wast source(s):below. A signature shall be
<br /> obtained from-a representative. from each' source, �erifying.'the ' yp
<br /> .te.'and quaatity stated.
<br /> If::'awre thanfour sources in filo waste -load; attach additional forms..' R,andca..verification
<br /> will be sada by .SRWCF..
<br /> 1. Name: Name:
<br /> '.:;... ..Address • .,
<br /> Addresas .
<br /> Zip
<br /> Zip
<br /> Phone No.?( )_.� .. Phone No.: )
<br /> Qunit
<br /> Waste .Type: Quatity ? flgal. Waste y: al.
<br /> Sigtaa 'ur, s `'.. gip' {' signature:..:
<br /> Date:, Time. '. Datet iTimes
<br /> Within S ocktmn city limits? .Yes No... Within Stockton �ity limits? Yea No
<br /> I. Name: 4. Name;
<br /> Address: Addrese:
<br /> yip yip .
<br /> Phone_No.:: ( ). Phone No.
<br /> Waste Types' Quantity: gal.,. Waste Type:. Quantity: gal.
<br /> Signature: Signature:
<br /> Date: Tiatie: A-X P.M. .' Date: Time: A.M. P.M.
<br /> Within S.toEkton. city limits? Yes No Within Stockton city limits'? Yea No
<br /> TOTAL QUANTITY (All Sources)t gal.
<br /> Allowable waste Type: Place applicable number in space probided .above. .
<br /> :1. Residential Septage, Z. Portable Toilet' 3. Restaurant :Grease Interceptor 4. Special
<br /> Disharge
<br /> ftwazu wil mot be mqukvd,but WMIm sod=Wom'pla'pmm shall be kdiaa cd.
<br /> "A SpocW Per"must be wmpkod and appiwod by S WC F bdfom diiahuza is dlowed...
<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 .1
<br /> now request to didpose.of at the SRWCF. I further declare, under penalty 'of perjury, that
<br /> I :was personally infokmed by'the owner, owner.'s agent, or :o.ccupants of the .property where
<br /> this waste was received 6r have .personal .knowledge, that this waste contain only
<br /> residential septage or grease, or in, the ',case. of' a Special Permit, is, not hazardous and.
<br /> does -not exceed"previously,author ized. limita., as per Pretreatmtent/Source Control
<br /> requirements. I .also. declare, under:penalty -of perjury, that.the teuek(s): used to
<br /> transport this. waste was free of all materials characterized by -law as a hazardous waste
<br /> or substance at the time of said use. . I am aware .ofthe 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'Hau.ler Permit and/or any. applicable
<br /> SRwcF regulation, may result in the immediate suspension of.my Waste Hauler Permit an or
<br /> other penalties as may be allowed by law.
<br /> Waste Hauler'Signature*
<br /> CREATIVE PRIWV4'(2Q9)466A>r8d
<br />
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