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1 <br /> IFROM FAX NO Jul. 28 2003 11:29AM P2 <br /> ..s >,n ;!n•:.x.x `i�:C. .>... 3' ^Pr, -.e.<. ..f.:o:wx �'if,x". <br /> ',t:t� S't".f:^ x:>!'!t >�... '!1.` "k> K ? .>'xi> J .J..!>>.� .5. •y.v� )itt ) <br /> 'Sr t :`K>'>�,• '.5,' � ���1��1��� �i4bx zz):i�<.x.v,ttx <br /> , , ',f ,,aa �.�y f "i y ./: y f :�`t i Y Y:�' ,.: :t)'•>.x^� y, �.x�.w_ <br /> ,e. <br /> TO :BE COMPLETED PY, WASTE. HAULER BEFORE '•ENTRY. To SRWCF :15150 <br /> t <br /> ftXA3H MR=AND-PYBe&liARD:.IIdC01� H OR.II.L80IDFB P01M&.WR-L N0T M ATPD: .-: <br /> Waste.'Hauler Company: ams .Vehicle Capacity <br /> Vehicle LicsnHe�No. ate lEey, # . . Load # <br /> coapleta naxey EdidreS61-ttyPev:'asd antity -4: a sourceC's) below.. A signature shall beobtained froa�'aapreaentative faros each source; .erffying-the type. 'and guantity .z.tated. <br /> if•'aore. than f sources.-in the:maste• load; :attach. additional- forms.. Rando..verification, <br /> will be Sade by..SRWCF.. . <br /> Z r Dame: <br /> raaregg: ( <br /> Address: <br /> 'Zi <br /> Phone No. ) Phone No. } '� <br /> Waste' TYPe^ 4uaiztitys.. al. Waste Type: : ant . ye v al. <br /> O.. <br /> Signatujt4,ktoci 3ignatur . <br /> Date: :.: Time: Date:. Time: . A. :M.Within ty limits? Yeo a Within :St ckto city limits? Yes No <br /> A. Names 4. :Name: <br /> Address: <br /> ..Address: <br /> _Z.,ip gip. <br /> Phone.No.:.. <br /> Phone No ( ') <br /> Waste :Type: gsantity: gal. Waste <br /> Type. Quantity: gal. <br /> Signature: signature: <br /> Date- Time: A:M. P:!!. Date: Time: A.M. P.M. <br /> Within 'stockton City: limits? Yea No.', Within Stockton city limits? . Yes No'. <br /> TY '(A1 es)s gal. <br /> TOTAL Qt1AliT2 1 Sonrc <br /> Allowable Waste Type: Placs applicabla nuober .in &Paco provided above. <br /> J. Resident ial .septage*... 2.. Portable Toilet' 3. .Restaurant Grease Interceptor 4,. Special <br /> Disharge" . <br /> swuum.WM00 be icpk*bus kwaeim and ne�pmnblo pomm abaRte i Wknied. <br /> A'.9pocial Aumit mat ba taia�flelod ad appuiavcd by SRWCF bo[c�o'disebaeYe is IIUwYed. <br /> I; the below named waste= hauler, declare under penalty,:of perjury, that to the best of my <br /> •knowledge Y 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, .unde'r. penalty of .per5ury,: that <br /> 1 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, septage or.grease; 'or'in 'the case of a Special .Permit, isnot hazardous,and <br /> does not' exceed previously authorized liatits, .as per Pretreatment/Source Control <br /> requirements. I also declare, under.penalty of ,perjury, that the trucks) used to <br /> ..transport this waste was free of all materials characterized bylaw as a .hazacdous waste <br /> or substance at the time of, .said','use. I am aware of the conditions and .requirements of <br /> the Waste Hauler. Permit. Further, 1 understand that failure to accurately describe the <br /> above information or. f'ailure to-comply with my Wasite Hauler Permit and/or .any applicable <br /> SRWCF.'requlation, .may result .in the immediate suspension of my Waste Hauler. Permit and/dr <br /> other.'penaltiee. as' may be allowed by Taw. <br /> Waste .Hauler signature <br /> CREATIVE PPoNTING(209)466-0288 <br />