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AMEMEMEM <br /> STOCKTON REGIONAL WASTE,;'ATER CON-TROT. FAC=Y <br /> 'WASTE HAULER M-- N FEST FORM <br />' TO BE CC'N�--T-- '=D BY <br /> WAS EE . _ �_Zp B�Fcp _ TC SRWC7 <br /> 5022 <br /> 4�-D ?R. 55 r-ALF7 IZNCoNL�,,*GR .wiL_ NOT 33 1CC-= r_..]* <br />' Waste Hauler Ccmpany Name �:� . V _ . -- <br /> - - eh_cle Canac_mv_ <br /> Veh-cle License No. �,��, =-L Date - �- <br /> - _ _� ~- 'Ke r if <br /> Complete name' <br /> a readdress, tF'ra, and <br /> obtaiaed fraa� quantity of waste source(s) below. A signature shall be <br />' presentat_ve from each source, <br /> If Sara than four souverifyingun <br /> the type and quantity stated. <br /> will be rade by SRWCFrces — the waste load, attach additional forms. Random ver .icatioa <br /> . i <br /> i <br /> Z <br /> Name: <br /> Address: ' r <br /> _ �- Zig <br />' Phone No. : ( , <br /> Waste Type: �,L/ <br /> Qu=�4it_r: � � gal <br />' <br /> Signature:���,�t <br /> Date: `Ti.-ne: <br /> - r..M. P.Y <br /> Within Stockton city 1_t_ts' Yes No S <br /> d <br /> J f <br /> Allowable Waste Type: Place applicable number ].II apace Provided above. <br /> I. Residential Septage' 2. PC--table Toilet' 3 Restaurant Grease Interceptor 4. Special <br /> Disharge- _ <br />' SCUUW=WM na be rcq med,ba keaam mod reqx=ao.e penin sLLo be mdac- <br /> A SP--W Pcn==14 be craapkted and approved by szwp7 beam <br /> d++ebuje a allowed <br /> I, the below named waste hauler, declare under zenaltr cf' per3ur~r, that to t^e Aest of my knowledge I have accurately described the type, quantztr, and source of a_1 wastes Wnich I <br /> now request to dispose of at =he SRWCF I f.ir•the; declare, under renalty of per3ury, that <br /> I was personally informed br .he owner, owner's agent, or occupants of the Frorer-ty where <br /> this waste was received or have personal knowledge, tnat this waste corta_Zs C-ly <br /> residential septage or grease, or in the case of a Special Permit, is not razardous and <br /> does not exceed previously a-t hcrized limits, as per Pretreatment/So_rce Control <br /> requirements. I also declare, under penalty of pe;3ur-r, that the t,�ck(a) used to <br /> transport this waste was free of all materials c.aractezized by la4 as a ;azari'cus .caste <br /> or substance at the tune of sa-d use. 1 am a4are of t:e acrd <br /> _tlong and rem <br /> of <br /> the Waste Hauler Permit. ;t:er, I understand that fa_lure to acc4ratelr�c�es�Ircribesthe <br /> ove information or failure to cpm 1 <br /> WCF re 1 P Y wi th my waste Lia"ler Permit and/or air atolica'nle <br /> 9u ation, may result in the immediate suspension. of mr Waste Hauler Pie=' it and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br />