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STOCKTON- REGIONAL WASTEWATER CONTROL FAC=Y <br /> 'WASTE HAULER MAN-=ST FORM <br /> tTO BE CCv-PLZ :D BY WASTE S.... Oic= ENT-RZ TO STR C.= 5059 <br /> K--ASF ?R--; !tti -L LNC-OkLn��"� ACC✓="'^:� <br /> �1 <br /> Waste Hauler Company ham �(-• Vez_c�e Cap ac_. r -.��9 <br /> Vehicle License No. fey --cad # <br /> Complete name, address, typ-e, aid quantity of waste source(z) below A signature shall be <br />' obtained from a representat• ve from each source, verifying the type and quantity stated. <br /> If more than four sources 'L= the waste load, attach additional forms Random verification <br /> will be made by SRWCP. <br /> 3. Name: en , <br /> Address: G - (/ <br /> lt� zip <br /> Phone No. ( , 1 ) <br /> Waste Type-. Quant-_y: 2 -72 '7, gal. <br />' Signature: <br /> Date: [.j-ZF'<7V1 Time: $ C,ZA.M. P.11. <br /> r <br /> Within Stockton city limits, Yes No <br /> J f <br />' Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage` Z. Por-table Toilet' 3 Restaurant Grease Interceptor 4. Special <br /> Disharge" - <br /> SWasairea.nom not ba esgU=d, bus 1--� od tmwp=zQs a pes,w sLL a be—d--,,A <br /> r A 9peeul Per=must be eamQIcUd and aMg d tr 5RWC7 befom d—h ge to silo-wed <br /> I, the below named waste hauler, declare under -enalty of perD-ry, t-at tc tre best of' my knowledge I have accurately described the tre, quart-ter, and source of all wastes which-I <br /> i <br /> now request to dispose of at the SRWCF I f-sr`-er ceclare, under penalty of Ter]try, t:-,at <br /> I was personally info=ed b., the owner, owner's age-,z, or occupants cf the property where <br /> this waste was received or have personal knowledge, tnat this .paste centa-ns only <br />' residential Septage or grease, or in the case c= a S=ec-a_ ?e=-t, :.s rot %azardous and <br /> does not exceed previously a..therized limits, as per- Pretraatme^t/Sc-rce Central <br /> requirements. I also declare, under penalty t-at %e _r1ck( s) used to <br /> transport this waste was free of all mater_a'_9 c-ara__e„zed br la.i as a razardous .,aste <br /> or substance at the time of said use. I a-m a..are of tie cord-t-ors an: reer-iremer_s of <br /> the Waste Hauler Permit. r� he_, I understand that fa-l-re to accarate'__r descrihe the <br /> above information or failure to comply Frith my Waste �%auler Permit a-d/or any appl_cable <br /> SRWCF regulation, may result in the tmroed,ate suspension am Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. l J <br /> i <br /> Waste Hauler Signature <br />