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FROM FAX NO. Aug. 30 2003 02:55PM P1
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<br /> i>SR },Y sS' j
<br /> a, v:i 3 kaal4ia r ) n..
<br /> 'l'O BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF:.
<br /> 20509-
<br /> ;;:.' KXASB PRM AND PROS HARD. IIi WWPTZM OR IIiMMMFORM WZL NOT HS ACCSPM.
<br /> 4 Waste Hauler.
<br /> company,'.'Nam
<br /> LA Vehicle Capacity
<br /> Vehicle Li,ionae N, ,o Rey
<br /> aa
<br /> %.•' ': Complete ae,..address t.type, and gaatititg f ste sources) below..A signature shall be
<br /> ' obtained.frog a.:rspresentatve from.each.source. verifying'the.type and quantity stated.
<br /> .If nors,than four sources.in-theMaste
<br /> load; attach additional-forms. Random, verification,
<br /> will be.,mads' Ai SRWCP..
<br /> 1.
<br /> Names2. Name
<br /> Address.
<br /> Address:
<br /> zip
<br /> Phone No rf ) Phone No.r
<br /> ::•..
<br /> Waste Type 4a tityt Qal.. Waste Type_ antit
<br /> y: 'gal
<br /> U gnature Signature-
<br /> Date...
<br /> ignature-
<br /> Date:. Tilpe: P.K. Date: Timer. A.M. P.M.
<br /> Within at ckto city limits? You l40 '1 Within Stockton city limits?` yes No,
<br /> E: 3.
<br /> Name-
<br /> 4. Name:
<br /> Afldrese:
<br /> ,.. .. ;'.
<br /> Address: _
<br /> '. 2 ip Zip
<br /> Phone No.:( NO.,(. ,
<br /> � Phone .
<br /> >,.....
<br /> Flaetq Type: Quantity: gal. /last- : antit
<br /> Type. 4u y:
<br /> - Signature: eignaturei
<br /> Dates Timei A.Ii. P.M. Dates time:. A.M. P..M.
<br /> Within Stockton city limits? Yee No Within.Stockton city limits.? you No
<br /> TOTAL QtnLNTITr tAll.Sources)1. gal.
<br /> Allowable +taste.Type: applicable nusiber in space provfded above.
<br /> 1. Residential. Septage' 2. `Portable Toilet' 3. Restaurant crease Intercepeor 4—Special
<br /> Disharge"
<br /> Si�wpue.wdl mt•be .bin looem and eapombb mmh, bo adiaw
<br /> "A 9peeiJ Pumit girt be 2anPlobd ed.opprmad by SRWCP bdm d6ahary is dlwed,
<br /> I, the below named.waste hauler, declare under penalty of perjury, :that. to the beet of my
<br /> . 'knowledge I..havo-:accurately described the type, quantity, and sdurce of al.l*"bastes which i
<br /> now request to dispose-of at the SRWCF. I.further declare, under penalty, of perjury, that.
<br /> T was personally informed by.the.owner, ow4pr'a agent, or occupants of the„property where
<br /> this waste.was received or have personal knowledge, that.this waste. contains only
<br /> residential oeptage .Or. grease, or in the case of -a Special Permit,. is z}ot.hazardoue and
<br /> r•:_'r,% does not ekceed:preaiouely. authorized limits, s per pretreatment/source.,Control .
<br /> requ rementi. I also declare, .under penalty, of.perjury, that the truck(a)::.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. ;:am: aware of �the: conditione and requirements of
<br /> the Waste Hauler,P.ermit >.•yurther, I,.understand that failure:to_accurately :describe the
<br /> above Information'6r failure to -comply with MY Waste Hauler Permit and/or•any applicable
<br /> SRWCF regulation, Wray jresult. in.the"immediate suspension of my Waste ler,':Permit 'and/or
<br /> other penalties a£3"may be,.allowed by law.
<br /> i.
<br /> Waste Hauler Signature
<br /> CRF Trm RRWWGM •Ia0G1 X6=$ -
<br />
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