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STOCKTON REGIO.,L, WASTEV,.-ITER CUNTROL FACLLI I Y <br /> WASTE HAULER '-NL2N7FEST FORM <br /> t <br /> TO BE CO'_mL-----ED BY WckST E _L=- 3-E:OR:_ .l:TRY :O SRWC F. 5060 <br /> PL .tiSE?2`tiT ,ti t ritL7�atiCt]4G� Q�2 L OiZ6S5 w2!�Oi BE Cc=D <br /> rTaste Hauler Ccmpany base Q� r Ver._cle Capac_t. <br /> _s3�7 <br />' ven_cle License No. Date 4- 2_5? ^GCI V <br /> _Key # cad # U -7pati <br /> Complete name, address, tye, -d quantity of waste scurce(s) below. As-guature ;hall be <br /> obtained from a representat- ve from each source, verifying the type and quantity stated. <br /> If more than four sources is the waste load, attach additional forms. Random verification <br /> will be wade by SRWCF. <br /> i . Name: <br /> Address- / <br /> ZID <br /> 1 <br /> Phone No. : ( ) '15 <br /> 1 <br /> Waste Type: Quantity: gal. <br /> Signature: _,--7 <br />' Date:4r- Time- Q .��.�A.Y. P.m <br /> T~ <br /> Within Stockton city 1 m==s' Yes No <br /> Mplo <br /> d <br /> 1 <br />' Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage' 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. Special <br /> Disharge` <br />' 51panun.rte voe be but 1oc�oan and m:Qmmcic paaoo shall be•a ,•-+ <br /> A Sp--W be==pk%cd aed npgrwad b7 SRWCP bd=drawarta a zlyQW*i <br /> I, the below named waste hauler, declare under =e-alty of per)sry, tzat to Mne best of my <br />' knowledge I have accurately described the tyre,�clanm-,m r, and source of all wastes which I <br /> now request to dispose of at the SRWCF. 14-=11,er declare, tnder penalty of perjury, that <br /> I was personally informed by the owner, owner' s agent, or occupants of t^e property where <br /> this waste was received or have personal kno+.,ledge, that this .paste cv:tai is only <br /> residential septage or grease, or in the case of a Special Permit, is not hazardous and <br /> does not exceed previously a_thozized lasn_ts, as per Pretrea=went/Source Cont_o1 <br /> requirements. I also declare, under penalty of per)ury, that tre tracks) used to <br /> transport this waste was free of all materials c-a-acterized by la.. as a zazardous ,caste <br /> or s4bstance at the time of said use. I an, a«are of the cond_tiors ara reg,..irements of <br /> the Waste Hauler Permit = -r-zher, I understand =ca= failure to accurate! r describe the <br /> above information or fa-li-re to comply with m/ +haste Mauler Permit and/or any applicable <br /> RWCF regulation, may result in the immediate sc,stersion a Waste Mauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br />