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i <br /> ser <br /> :tan:s:j: <br /> iFEFi <br /> firF:: <br /> a' <br /> :s <br /> . .. ... R.. k kM..... .. .... .a..45.1...F.:......, .. or:::...cx.t...<....;n:>:>.,.: '::•v y..... .r.f.. n{'' A;xV n{:{�i�": <br /> \r. v 3t iT,'si; .,:•';;?i;�i�::..... ......... ........ ...:::..:.. .).. i..3:E..<:3: <br /> ..:.,,.,,,.i s,.t?...L>2....... ,< ._ < .oxr:.o;:ka..z,.:<'�� :et`vin:•: <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 20510 <br /> PLEASE PRM AND PRPSS HARD. INCOMnZTE oR ni.HomiqoRhis WILL NOT HH ACCEPTED. <br /> Waste Hauler Company Name• Vehicle Capacity V <br /> Vehicle License No. Data Rey # Load # <br /> Complete nano, address,' ty e,� and quantity\o wa to sourc:e(s) below. A signature shall be <br /> obtained from a representative frow .each source, verifying the typo and quantity stated. <br /> If more than four sources in tho. waste load; attach additional forms. Random-verification <br /> will be made by SRWCF. <br /> 1. Name r 2. Name: =� <br /> Address: Address:; <br /> Z ip---; _• 8 i p <br /> Phone No.: ( ) (z,- Phone No. t ( <br /> Waste Type.%Quantity: r C� gal. Waetle Type: <br /> 'Quantity: al. <br /> Signatur SignatureJ_J <br /> Date: .L Timet CA.H. M. Date: Timer <br /> Within St ckta City limiter Yes o Within Sto6kto city limitta7 Yes (moo\ <br /> 3. Name: 4. Name: <br /> Addrese: Address: <br /> zip Zip . <br /> Phone No. :( ) Phone No. : ( ) <br /> Waste Type: Quantity: gal. Waste Type:_ Quantityr gal. <br /> Signature: Signature:_ <br /> Date: Time: A.M. P.M. Date: Time: A.M. P.M. <br /> Within Stockton city limits? Yes No Within Stockton city limits? Yea No <br /> TOTAL QUAMITY (All Sources): gal. <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 /> S4=huo wM r"be=q=rd,but kcabm and ec%ww"pmam shall be wdicaad. <br /> "A Sle : t,twk meat bo c=pktod and Wpw and by SRWCF beh=dischuEc is alloo•�. . <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 persoAally 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 o'f perjury, that the truck(®) 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. 1. 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 %d/or, <br /> other penalties as may be allowed by law. <br /> Waste Hauler Sigusture f <br /> CREATIVE PAINnNO(209)406-0288 r <br /> Id WdLS:ZB 200E 02 '6nd ON Xdd W08 <br />