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r <br /> STOCKTON REGIO.N.kL WA.STEWATEER C011,4-TROT F AC=Y <br /> WASTE HAULER NLA-N-IFEST FORM <br /> rTO BE BY WASTE -1�_:R 5T±oR. E�:1-Ri TO SRWCF. 5063 <br /> ?--°.kSE PR_"ti 14] RA2D Coke QZlZ =r 3_E FGR-L5 WIL_ tioT 3c A <br /> Waste Hauler Company NameC� /�I&L.� Ca_ac-tr -3 <br /> r <br /> Vehicle License No Date �7— � G� F e v :.cad it <br /> Complete came, address, type, a=d quantity of waste source(s) below A signature shall be <br />' obtained from a representative from each source, verifying the type and quamtity stated. <br /> If more than four sources a.= the waste load, attach additional forms. Random verification <br /> will be wade by SRWCF <br /> Address: <br /> Z=p i <br /> Phone No. : ( 3 S in 7 <br /> Waste Type: Quart_ty:2—7673 gal. <br /> rSignature: <br /> Date: ?L gY Tune: A.H. P.M. <br /> Within Stockton c-tv l=its? Yes No <br /> r )aQ �^ <br />' r <br /> J 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 /> Sgn=u Y w M nos be ee4,wrd,ba L--. and ragxx=6b a pe: zb3 be-Amts! <br /> A Spawn!P==A must be cnmp]eted Bad appt b+ =WQF bdom do_b c is&Llowed <br />' I, the below named waste haL ler, declare under penaltr of per3ur-y, t-at to the best of ny <br /> knowledge I have accurately described the typcr <br /> e, uart_ty, and source cr all wastes whica I <br /> now request to dispose of at the SRWCF. fs—ner declare, under penalty of per3uzzy, that <br /> I was personally informed by the owner, o..rner' s agent, or occ-pants cf the property where <br />' this waste was received or have personal knowledge, t.at this „ ante co-tains only <br /> residential Septage or grease, c= in the case of a S_ecial Pe=-t, _s -ct hazardous a-nd <br /> does not exceed previously a-therLzed li-mits, as p-er ?retr=agent/Source Ccrtrol <br /> requirements. I also declare, --o'er penal-,y cx t-iat t-e _=_ck( a) used to <br /> transport this waste was free of all mater-als --aracter_zed br taw as a hazardous waste <br /> or substance at the time of said use. I a.-, a..aae of _he cond-z-ors a-�d re�_reMents of <br /> the Waste Hauler Permit Fi ,=ther, I understart.at �a_lwre n acc-ra_elr deacribe the <br /> ove information or failure to comply with myynaste uauter Permit a-d/or am applicable <br /> SRWCF regulation, may result in the immediate e.spena_on of M y Waste r.auler Permit and/or <br /> other penalties as may be allowed by la4 1 <br /> Haste Hauler Signature -- <br /> r i` <br />