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STOCKTON REGIONAL WASTEWATER COh"TROL FAC=Y <br /> W.'kSTE HAULER ML-�-\-IFEST FORM <br /> I* I <br /> TC BE CQ12LB"BD BY Nr STT TRS' TC S RW5024 <br /> 4AR.7 r-NCokc- G? G.�.=FO;L%AS',k-j-_1,0-1 BE A.C= -D <br /> Waste Hauler Cacnpany Name ��� ,� l , — <br /> 4 � � � 'vei_cle Ca-a-_,r <br /> vehicle License No. ���- r % Cate Kay # :.cac # <br /> Complete naase, address, types, and quantity of waste source(s) below. A signature shall be <br /> obtained from a representat-ve from each source, 7erjfy1n9 the type and qi.a-n4ity stated. <br />' If more than four sources j_= the waste load, attach additional forms. Random verification <br /> will be made �by7 sRwCF. <br /> 1 Name. <br />' Address: <br /> Zit <br /> Phone No. : ( <br /> Waste Type: —Quantity: �_ gal <br /> Signature; ._! <br />' Date: A.M. P.H <br /> Within Stockton city l=_, <br /> t5? Yes No <br />' V <br /> t <br /> i r <br /> 3 <br /> 1 <br /> S <br />' Allowable Waste Type: place applicable number s.n space provided above. <br /> I. Residential Septage' 2. Potable 'Toilet' 3. Restaurant Grease Intercepter 4. Special <br /> Disharge- <br /> .5 IV— a-M mar be reaued,b*a kxsum nand rCMX=M&hk Prim ah4 be ndrat.-d <br /> A-1jmcW Pcrma m=be k:ed and approved by szwCp haara darbaae n Ocwcd <br /> _T the below named waste hauler, declare under _eena'_t r of ger3u=y, t-at to tae best of my <br />' knowledge I have accurately described the type, c-sartitr; and source of a_1 castes inxch I <br /> now request to dispose of at the SRWCF. I furvrer declare, under penalty or :er3ury, that <br /> I was personally informed by the owner, owner's a;ert, or occupants of tae =r-=per---y .There <br /> this waste was received or hale personal knowledge, m:at this waste costa-ns cily <br />' residential septage or grease, or in the case of a Scecza? Pe W'it, is rc_ na_ar:ous and <br /> does not exceed previously authorized li,zn,=s, az c-er- Pretreatmen=/S�Lrce Cortrzj <br /> requirements. I also declare, under penalty c= rer�-ry, tzar tae tru4,c( s � usedto <br /> transport this waste was free of all saterLals c-arac-er-zed b_, la.i as a ra_aroous .caste <br /> or substance at the tine of said use I a.-. a.rare of t-e cord_ticns and req,.._Zame-:ta of <br /> the Waste Hauler Permit. Fur_`:er, I understand :rat fa.yure to accirazeli desozibe the <br /> above information or failure to Comply with my Waste ra.ler Permit aid/cr anv applicable <br /> WCF regulation, may result in the immediate suspension of my Waste Hau.ier Perm <br /> ther penalties as may be allowed by las . it aid/or <br /> Wast % <br /> e Hauler Signature <br />