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STOCIKTON' REGION , WASTES ATE_R CONTROL FAC=Y <br /> WASTE HAULER NL-,\_N FEST FORM <br />' TO BE CO: y�'ED 3Y W'%ST- LiE.c 3-E-OR. ;NTRY TO S'WC=- 5021 <br /> Fi_?.1SE P "ti: t`"�%',RFS5 r_i2D Nc^okelz�_QZ_ tiQT 3E 1C^`_ <br /> Waste Hauler C:.mpany Name /�- �i ,c �� r Ver,_c'_e Ca;ac_t., } <br /> Veh_cle License No. - _ _ <br /> Date Ke r if _.;.ad # <br /> Complete name, address, type, amd quantity of waste source(&) below A signature shall be <br />' obtained from a represeatat_ve from each source, verifying the type and quantity stated. <br /> If more than four sources zn the waste load, attach additional forms Random verification <br /> will be made by SRWCF. <br /> Z Name: -�- <br /> Address: !� <br /> X1.5 Z in <br />' Phone No. : ( ) 3� <br /> Waste Type: 1 1/ , quern=_ r: �� '� gal. <br />' Signature: <br /> Date. l 1'_ - 4 Time: A.H P.H. <br /> Within Stockton city ljtits? Yes No <br /> m.• - <br /> a <br /> J r <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage` 2. Portable Toilet' 3. Restaurant Grease Intercector 4. Special <br /> Disharge" - <br /> Sgaawca WM nm ba re qu=d,but l--a and ro oc=z2bie p=-xm,heli be w-4—t d - <br /> A 3Qeeut Permit must be eocVk%ci add approved b7 Mt W(7 hd=diwbarge is allowed <br /> I, the below named waste hauler, declare under -eialt., of ner3ur), , treat to t:e best of my <br />' knowledge I have accurately described the type, qua-.z_ty, and source of a_1 castes .ih-,ch I <br /> now request to dispose of at the SRWCF. I f-m-,her declare, under pe-:altr of _er�ur-y, that <br /> I was personally informed by the owner, owner's agent, or occupa:lts of t^e pr�:_erty where <br /> this waste was received or have personal knowledge, that this .paste conta_ns crly <br />' residential Septage or grease, or in the case ofa Stecial Perm-t, is nc: hazardous and <br /> does not exceed previously auther, zed 11-nits, as Zer� Pzetreatment/Source ccr-tw�l <br /> requirements. I also declare, Lnder penalty of rerDLr-x-, that the tr-uck(s ) _sed to <br /> transport this waste was free of all mater-als c-araccerized by laa as a ra_aztous .caste <br /> or substance at the time of said use. I a.-s aware of zie conditions ana recr__ ements of <br /> the Waste Hauler Permit. u=her, I understand tiaz failure to acc-,rate'_, describe the <br /> ave information or fazlt.re to comply mr Waste Hauler Permit a-d/or any applicable <br /> RWCF regulation, may result in the mediate �i. <br /> suspersion of my Waste Hauler Pet and/or <br /> ot �m <br /> her penalties as may be allowed by law. <br /> Waste Hauler Signature <br />