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S <br /> STOCKTO.. xZ_EGIO I;AL WASTEVI�ATER CONTROL FAC=Y <br /> 'WASTE HAULER NL-NIF'EST FORM <br /> TO BE C^1M_77_ r_D BY w?STE BD-ORF. EvN�TRf TO SRWC- <br /> �_° 5064 <br /> 2R_"r A ti� titi 3 �StiCJ'.L� OR =CBI.:=0?_%S NOT HE ,G17�-�"KD <br /> maste Hauler Company `+aYe ver._cle capa__t r <br /> Vehicle License No late _ey #_ I :.mad f <br /> ComPlste name, address , tie, a.ad quantity of waste source(s) below A s_g=ature shall be <br /> obtaa..aed from a representative from each source, vertfying the type and quantity Stated. <br /> If -ore th&a four sources ;-n the waste load, attach additzoaal forms. Randa- verification <br /> will be rade by SRWCF <br /> 1. Name: r <br /> Address:-- - <�7 <br /> Z ip <br /> Phone No. : ( ) Ct <br /> Waste Type: t} quant =f• gal <br /> Signature: 4f <br /> Date: � �-( Time:,1 A.H. P M. <br />` Within Stockton city 1�=_s? Yes No`s <br /> a+ <br /> " r � <br /> i f <br /> X <br /> ` S <br /> i r_N 44 <br /> Allowable Waste Type: place applicable number iu space provided above. <br /> I. Residential Septage` 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. Special <br /> ' %shaxge" <br /> 'Svuh==.-M ss be rte,bLd;X4LW n and re-J a p— shaa b.-- <br /> A <br /> eA$pass!Fama moa be ceaupkud mad germed by SRS CP bet=&wh.to a iawtd <br /> ' I, the below named waste ha,-lea, declare under :eralty of perjury, tnat tc t1^e nest of my <br /> knowledge I have accurately described the type, quantity, and source of all wastes wr.ich I <br /> request to dispose of at t-e SRWCF. I further declare, under penaltyof perjury, that <br /> ,now <br /> I was personally informed by the o�rner, owner's agent, or occupar.ts of the crcperty wnere <br /> this waste was received or race personal knowledge, that this waste canta_ns onl, <br /> residential septage or grease, or zn the case of a S=ec,al Permit, -s not nazardcus and <br /> ,does not exceed previously a-t^orized li-mits, as Per-pretreatment/source control <br /> requirements. I also declare, under penalty of per3;.r.r, tea: the truck( s) used to <br /> transport this waste was free Cif all mater..als cna;acterzzed by 1a.r as a ^azardcsa .caste <br /> or substance at the t=e of said use- I an a.rare of _re cordztions and recv�rementa of <br /> the Waste Hauler Perm_Lt 5",„7t: er, I t.nderstand that fa-lure to acclira~el. describe the <br /> ove information or failure tc comply with cry Aaate hat.l.er P rmit a-^d/or ant applicable <br /> WCF .regulation, may result the immediate s..s a^szon of m Waste naliler rerm.t a-id/or <br /> er penaltLez as may be allow ed by law. <br /> Waste Hauler Szgnature� <br /> r <br />