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1 <br /> STOCKTO" REGIONAL WASTE .A Trr.R CONTROL FACT -T Y <br /> WAS= I-LAC_;LER M- N7r^EST FORM <br />' To B: CC!-L-FL__ZD B.� WAST- : A.t7_ZR BE-4IRZ TO S:WC: 5058 <br /> P' 151c k. C CI `"`in �w;OF_MS WE ',0 i HE 1CC"H =3 <br /> Waste Hauler Ccmpany h� a � i(�_� e� r, �e^_cle Ca=ac-- <br />' Vehicle License No. Date^4-1 -) 5t)gt}_�ef # �_ `.oad # <br /> Complete name, address, type, and quantity of waste source(s) below A s_gaature shall be <br /> obtained from a represestat:ve from each source, verifying the type azid quantity stated. <br /> If ware than four sources sem. the waste load, attach additional forces. Raadom verification <br /> will be made by SRWCF. <br /> 1. Name• <br /> Address: C <br /> Zip <br />' Phone NO. : ( ) <br /> Waste Type--- f Qu3^tz-y: gal. <br /> Signature: 7777 H1 <br /> bate: r Time. /'� _'17r1 A.M. P M. <br /> Within Stockton city l—rts? Yes No <br /> i <br /> 1 11 � <br /> 3 <br /> 1 <br />' Allowable Waste Type: Place applicable number space provided above. <br /> 1. Residential Septage' 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. Special <br /> DLsharge- _ <br />' 94tamics wM am be roguaed,bia ic+cat)cm and,- p---Ic peram ibAM be mdr�cd <br /> A Bp=4 P==A mesa be ke Md zpcToycd b7 SRWCF betas deaebas=o a&Bowed <br /> I, the below named waste haLler, declare under penaltf of peer3ury, =-at to t-e best of my <br />' knowledge I have accurately described thet,._e, cua;:tz-y, and source of all .castes which I <br /> « <br /> now request to dispose of at the SRWCe. Fsrrher declare, under penalty oc ter)ur-y, that <br /> I was personally informed by the owner, owner' s age-it, or occupants of tie p oerty where <br /> this waste was received or have personal knowledge, t.at this .caste contains�;ally <br /> residential septage or crease, or in the case of a Special Permit, -s not '^a_a=dcus and <br /> does not exceed previously a_thcrLzed limits, as =er Pretreatment/Scurce Cc-t_ol <br /> requirements. I also dec: are, L—der penalty o: tnat the ___c c( s) -sad to <br /> transport this waste .cas free of all mater_als c-arazterized br la. as a -aza_cots waste <br /> or substance at the ti-e cf said use. I a- aware of _-e cc^dLt'ons and rem__cements of <br /> the Waate Hauler Permit ���her, I undersea-d _-at aa-lure to accurate_ r describe the <br /> ra,bove <br /> information or '6a-!,-re to comply with my 4aste "ailer Permit aid/cra- r applicable <br /> WCF regulation, may res-It in the immediate sisaension my Waste Fuller PermLt and/or <br /> ther penalties as may be a_lowed by law. <br /> Waste Hauler Signature <br /> 1 / 6T <br />