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STOCKTON REGIO. AL WASTF-NVATER CON. `TROL, F AC=Y <br /> WASTE HAULER -M-32N"LFEST FORM <br />' TO BE CC:L— =-D Bi h3%.ST .,��=� �. =C �al��r TO SR C_ 5023 <br /> PLC.ISH <br />' Waste Hauler Compa-nv Na-e , �_. ._�_. -�Y .l ve-^_c;.e Ca_ac_=v <br /> Vehicle L-,Cense No. C/�^ � Date t- %ey # cad t <br /> Complete name, address, type, amd quantity of ua-ste .sou.-"ce(s) below. r1 signature shall be <br />' obtained from a representative from each source, verifying the type and quantity stated. <br /> If more than four sources the waste load, attach additional forms. Random -verification <br /> will be wade by SRWCF. <br />' 1. Name: <br /> Address: /f ')/ / ! j4„ UMUR <br /> zJ.n <br />' Phone No. : ( <br /> Waste Type; "� Qti.a: v: ' gal <br />' Signature: �t _ <br /> Date: U �- `- 1 'Tune ? P.H. <br /> Within Stockton city Yes <br /> t <br /> s <br /> ` I 3 <br /> I <br /> 1 <br />' Allowable Baste Type: Place applicable number_ in space provided above. <br /> 1. Residential Septage- 2. Portable Toilet" 3. Restaurant Grease Interceptor 4. Special <br /> Disharge— _ <br /> Swunn=WM mot be-q—ed,but k-b=md rap=--b1e person shag be mdwaced <br /> A Sp=u1 Puma must be Iaed and spFrpv-i by MWCF belorm dLrr� .a au1 cd <br /> I, the below named waste hauler, declare undeF salty o. pe�u.y; t^.a. to t,e `bes:. of my <br /> knowledge I have accurately described the type, quant-_y, and source of all .castes which I <br /> now request to dispose or at the SRWCF. ' I fu=ner deciare, under penalty of rer3ury, that <br /> I was personally informed by- the owner, owner's agent, or cccupants of tate Property where <br /> this; waste was received or have personal knowledge, meat this waste contains only <br />' residential Septage or grease, or in the case of a S_cecia_ Permit, is not hazardous and <br /> does not exceed previ.ousir a..thorized limits, as per Pretreatment/Source ccrtrol <br /> requirements. I also declare, under penalty of t-at tie tr~sc,t( s) used to <br /> transport this waste was free of all materials craracterized by law as a hazardous waste <br /> or Substance at the t=e of said use. I am a.rare of tie conditions and rem_rements of <br /> the Waste Hauler Permit. :.:cher, I understand that fa-lure to accurately describe the <br /> above Information or failure to comply with my Hm <br /> Haste hauler Permit and/or any applicable <br /> SRWCF regulation, may result in the immediate auspens ion of m., 4aste Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br /> 1 <br />