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STOCKTON REGIONAL WASTE�� .TER COIN-TROL FAC=Y <br /> WASTE HAULER INLANIFEST FORM <br />' TO BE COK-PL, _DD BY WASTE BEFORE ZD+';Re 70 S�RWCi 5065 <br /> PLASP P;Z� CMwt- G LMS t4"_ ',CT BR A,=Z7—:-_D <br /> Waste Hauler cmmpany Na.=e <br /> Vehicle License No. Date Q.-2 - Lf -Key if :.=ad it <br /> Complete name, address, type, and quantity of waste source(:) below. A signature shall be <br />' obtained from a repro sentat_va from each source, verifying the type aad quantity stated. <br /> If -ore than four sources the waste load, attach additional forms Random verzfacata.on <br /> will be made by SRWCP. <br /> i <br /> 1. Name: <br /> Address: I S -r--- r <br /> Zip <br />' Phone No. : ( ? `� <br /> Waste Type: Quantw-,r:�3q 3 gal. <br /> Signature: - <br />' Date: P -22 -9t4 Time: ' A.M. P-M. <br /> Within Stockton city Yes No IL <br /> gut <br />' Allowable Waste Type: Place applicable number space provided above. <br /> 1. Residential Septage` 2, Portable Toilet' 3. Restaurant Grease Interceptor 4. Special <br /> Disharge" <br /> SePamn.-iD cwt be raqwrcd,but la=nm and rcq+=ziio pm-wa x4a be ndr_atd <br /> A SpecW Perms retia be k%cd and appcwcd by StWCF before duchagc as.a,,wed <br /> I, the below named waste hauler, declare under ce:a'_tv of per-az-y, _-at to tie best of my <br />' knowledge I have accurately descr:.bed the tyre, cuant_ty, andsourcecf all wastes which I <br /> now request to dispose o: a_ the SRWCF. I Furt'7er declare, under renaltr of per)ur~y, that <br /> I was personally informed by the owner, owner' s agent, or cccspants of t.`.e pro_erty where <br /> this waste was received or have personal knowledge, t`�at tnzs waste caz_a_ns erly <br /> residential Septage ar crease, or in the case of a Special Pe=,t, is not nacardous and <br /> does not exceed previously a__horzzed limits, as per Pretreatuert/Source Control <br /> requirements. I also declare, under peral-; o. per]uwr, tnat _~�e �_ .c' (s} used to <br /> transport this waste was Free of all mater ala _^a_acter_xed e, law as a r.acardaus .caste <br />' or subtance at the ti-me of sa-d use. I am a.ra_e o; the cor,d_t_o-�s a-d regL_renents of <br /> the Wasste Hauler Pe=lt F- —':er, I unders-a-�d tnat faille to accuratel i aescrLbe the <br /> eoa� <br /> ove information or fa_l�.re to coaply withrFJm� Waace a:� ^mer Pe _t a-d/or a-a- ,, applicable <br /> WCF regulation, may result -n the �nediatesLspi.ensanl ,. Wasteof maste Fa-lez -Permit and/or <br /> ther penalties as may be allowed by law. <br /> Waste Hauler Signature C� � <br />