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STOCKTO T REGIONAL ''ASTE WATER CONTROL FACILITY <br /> WASTE HAULER MA-\-IFEST FORM <br /> 1 TO BE C'J_'�==Z'c T� BY WASTE w <br /> rijT� _,' :.�.�' BB;Q� ^.'rT�;L 70 SRWCF. 5061 <br /> Waste Hauler Company N,_,' <br /> Pt—?.15E PR.'` ND ri4.�7 LtiCO�£�!=—� vinic�ORI.IS 4�T�' 1CY'3c �C=y—r_D e r <br /> i Vei_cle Cacaz-t. Q <br /> Venicle License No. Date <br /> CQ/, Load <br />' Camplete name, address, type, and quantity of waste source(s) below, .� signature zhaZl be <br /> obtained from a representative from each source, verifying the type and quantity stated. <br /> If more than four sources -n the waste load, attach adda.taonal fors Random verification <br /> will be made by SRWCF. <br />' 1. Name: <br /> Address: <br /> Zn r t <br /> Phone No. : ( ) JC"� t <br /> Waste Type: Quant--Y= gal. <br />' Signature: y� <br /> Date: r`? cJ(LTirne: in A.M. F.H. <br /> Within Stockton city 1_-11 Yes *10 <br /> a <br /> t <br /> � C t <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 /> swmanuw wM am be rn but locacaa and r=pcQxii k pn-�ihka be—:hcucd <br /> A SP=w l P=md ML=be o=apincd and spprmod by SRWCF bolas draehAq <br /> I, the below named waste hauler, declare under ne-:aLt., of eZ)url, tra_ tc tre best of my <br /> knowledge I have accurately descried the type, quar:tity, and source o. a,'_ .castes which I <br /> now request to dispose of at the SRWCF. I fur-tier declare, under pe-ally of ger�ur-y, that <br /> I was Pereenally informed by the owner, owner's agent, or oCC410ants of the property where <br />' this waste was received or have Personal knowle?rz, tzat anis ,aaste co�tatns only <br /> residential septage or grease, or in the case c= a S=ec-al Per-=_t, - <br /> haza <br /> does not exceed previously a-_horized limits, as c-er PretreatWent/So"rce�Ccntrolous and <br /> requirements. I also declare, under penalty o= cerD-ry. , iia- the t_-c4 s) us ed to <br /> transport this waste was free of all materials c^a,ac=erzzed�by law as a nazardaus waste <br /> or sibstance at the time of said use I am aware of tie cord_ticns and req~_�remeits of <br /> the Waste Hauler Perm-, t. ;u.Cher, I understand that failure to accsrately describe the <br /> ave information or failure to coa:ply with mi waste Hauler Permit and/or any applicable <br /> RWCF regulation, may result -n the immediate suspension of my Waste Hauler Permit and/or <br /> other penalties as may be allowed by law <br />' Waste Hauler Signature <br /> 1 <br />