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1 , <br /> STOCKTON kEGION AL �AS 1_NVATER CU-NrTROL FACZLITY <br /> WASTE HAULER hL-_N FEST FORM <br /> TO BE CCH-_-!_=D BI WASTEk—,1�, Z? 8. :ORE ENTRY TO SR Cr 5062 <br /> PL c1SE?,Z� 1� =tib CO4re:='Oa L:--:rORkO'Xa—NOT BE <br /> +paste Hauler Company Na.=eY �,� [,U / u� Ven_cle Capac__. <br /> Vehicle License No. Date 1U - 77 Ur -<e r # =oad it <br /> Complete name, address, trpe, and quantity of waste source(s) below A signature 1ha11 be <br /> obtained from a representat-ve from each source, verifying the type and quantity stated. <br />' If sore than four sources L. the waste load, attach additional forms Random verification <br /> will be <br />' 2 Name: 1 . <br /> Address: nSUR <br /> Phone No. : ( )�{ � �S'r;-7 ^�� � <br /> Waste Type: Quan__=;r:2-'��_7�gal- <br /> Signature: <br />' Date: L Time: A.H. P H. <br /> Within Stockton city 1t-t__s' Yes No <br /> Z <br /> i <br /> t i <br /> J� t <br /> E <br /> i <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 /> "Sw---M am be:egarcd but lava=artle pe„s Lh.n be %d,.,,d <br /> A 4--W Perms mua be emdplmed and W rwcd b+ stWCF b.Jm-.daacba.n,M AD zd <br /> I, the below named waste tauler, declare under _enaltr of per)urr, that to t^e best of pry <br /> knowledge I have accurately described the type, c-uartity, and source of a-1 wastes which I <br /> now request to dispose of at the SRWCF. I fur`^er declare, under penalty cf ter3urf, that <br /> I was personally informed br the owner, cwrer's a;ert, or occupants of the property where <br /> this waste was received cr have personal knowledge, tnat th-a .caste conta_ns only <br />' residential septage or grease, or in the case o' a Special Peet, is not hazardous and <br /> does not exceed previously a-=hor__ed lim_ta, as ce; Pretreatment/Se_rce Control <br /> requirements. I also declare, under penalty o: _erDurf, teat the _cx( s ) used to <br /> transport this waste was free of all mater-als c-a=acterizec hr la,; as a nazardous .caste <br /> or substance at the time cf said use. I an a4are cf the cord-Mi,")^s and requirements of <br /> the Waste Hauler Permit. Lr-ther, I Lnderstard t,a� fa_l�..re to accsrateir describe the <br /> above information or fa-lure to comply with mr maste hauler Pe=it a^d/cr a"r applicable <br /> RWCF regulation, may re sit in the immediate slip <br /> sers_on o° v Waste uauler Permit and/or <br /> other penalties as may be allowed by law <br /> Waste Hauler SLgzatur <br /> C� <br />