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STOCKTON REGIONAL WASTEWATER CONTROL FACILITY <br /> WASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. <br /> PLEASE PRINT AND PRESS HARD. INCOMPLETE OR II-LEGIBLE FORMS WELL NOT BE ACCEPTED. <br /> Waste Hauler Company Name Vehicle Capacity <br /> Vehicle License No. Date Rey # Load it <br /> Complete name, address, type, and quantity of waste source(&) 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 waste load; attach additional forms. Random verification <br /> will be made by SRWCF. <br /> 1. Name: <br /> Address: <br /> i <br /> Zip <br /> Phone No. : ( ) w i _ <br /> Waste Type: Quant' ty: gal. <br /> Signature: _ <br /> Date: ! Time: �.�_ A.M. P.M. <br /> Within Stockton city limits? Yes No <br /> s. <br /> s <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 /> Signatunoa will not be required,but location and responsible person shall be indicated. <br /> A Special Permit must be completed and approved by SRWCP before discharge is allowed. <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 Septage 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 by law as a hazardous 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, I understand that failure to accurately describe the <br /> above information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> SRWCF regulation, may result in the immediate suspension of my Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br />