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STOCKTON REGIOIN:kL WASTEWATER Cn.N, =OL FAGIL.ITY <br /> WA-STE HAULER MAN =EST FORM <br />%0 -- <br /> TO BE COX,-LL_=D 3f WkST.. 3---:ORE ENTRZ TO SRWC-.- 5025 <br /> PL2.1SE FP—N 1.',--�, 7.V-:_SS --A-Zo D,Co 0R fir.;=0RNS IxILL.1,0 BZ� kCCz.7—D 1 <br /> � l <br /> Waste Hauler C^mpany NaWe �� - [: r-� - Je :_cls Ca ac_ty <br /> ~' <br /> Vehicle License No. �� ^� j - Date - �i{ey # load if <br /> Complete name, address, type, and quantz.ty of waste scurce(s) below. A signatsre shall be <br />' obtained from a representatwve from each source, ver;.fyang the type and quantity stated. <br /> If more than four sources in the waste load; attach additional forms. Random versficatLon <br /> will be wade by SRWCF. <br /> 1 a� <br /> 1. Name: <br /> Address: <br /> Zio S~2 i <br /> --- <br /> Phone No. : ( ) � <br /> Waste Type: gL a-1t..y: - gal. <br />' Signature: <br /> t <br /> Date: -��� Time: M P.M <br /> Within Stockton city 1--nits? Yes �No ` r <br /> f <br /> 1 <br />' Allowable Waste Type: Place applicable number a-n space provided above. <br /> 1. Residential Septage" 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. Special <br /> Disharge- <br /> Sgaannes WM am ba eared,bum$,canoe and le perxx shad be—d-4 <br /> A 3pccW Permit wuA be ksod mod zpp[vw d b7 SRWC?bdwe duchmic ea a1lowcd <br /> I, the below named waste hal-ler, declare under _enalty of per)u_y, t-at to t',e best of try <br />' knowledge I have accurately c'escr=bed the type, cuantity, and source of all wastes which I <br /> now request to dispose of at the SRWCF. r ft,. --ner declare, under penalty of rerjury, that <br /> I was personally informed by the owner, owner's agent, or occupants of the property where <br /> this waste was received or have personal k=nowledge, tnat this waste contains cnly <br />' residential septage or c=ease, or in the case of a Special Permit, is not hazardous and <br /> does not exceed previously a..thor_zed limits, as per Pretreatment/So4rce Cortrol <br /> requirements. I also decware, under penalty of _erDLr-y, that the L_..ck( s) Lsed to <br /> transport this waste was free of all mater_als characterized by la-w as a nazardous Taste <br /> or substance at the time of said use. I a--,i mare cf the conditzors and requirements of <br /> the Waste Hauler Permit. =Lrzher, I understand tra, _a-, 1u+e to acczrately describe the <br /> ove information or failure to comply witn my 4aste Hauler Permit and/or any applicable <br /> RWCF regulation, may resL.lt in the immediace suspension of my waste gauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br /> 1 �J , <br />