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er's Signature <br /> <br />CITY OF TRACY—UTILITES <br />WASTEWATER TREATMENT PLANT <br />3900 Holly Drive, Tracy, CA 95304 <br />(209) 831-6331 <br />TRACY vyy <br />Think Inside the Triangle - <br />SEPTIC TANK DISCHARGE REPORT <br />Day \)cVn5\ Date \? <br />f) <br />License Plate # V.--A) I 91 Truck Capacity (gallons) LLT:ic -c_cr.rcy. <br />Company Address <br />1. Customer Name Qikibilk-- 2. Customer Name <br />Address Address <br />Waste Type*: Septic Cesspool P Other Waste Type*: Septic Cesspool PT Other <br />3. Customer Name <br /> <br />4. Customer Name <br />Address <br /> <br />Address <br /> <br />Waste Type*: Septic Cesspool PT Other Waste Type*: Septic Cesspool PT Other <br />*Waste Type: circle one; if "other", specify type. PT = portable toilets <br />A complete and valid discharge permit must be on file and all past billings paid up-to-date. The truck must be in compliance with all <br />California Health and Safety Codes and regulations of the San Joaquin County Local Health District. Failure to correctly complete <br />this form, attempts to falsify information, failure to clean-up discharge area, attempts to discharge prohibited materials and/or any <br />other violations of permit requirements can lead to permit suspension/cancellation, fines, and possible imprisonment. <br />"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance <br />with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my <br />inquiry of the person or persons who manage the system, or those pe,ons-direcfiy responsible)ør-gatherii. the information, the <br />information submitted is, to the best of my knowledge and belief, tru-, .ccurate, and complete. am 6 e th there are significant <br />penalties for submitting false information, including the possibilit if fine and im risonment f .knOwvio ions.' <br />(For City of Tracy Use Only) <br />Inspector/Sampler Date <br />Observations: Color pH Other: <br />Laboratory analyses taken: Metals O&G TPH Other <br />Time <br />Company Name