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STOCKTON REGIO AL W ASTER- T ER CONTROL FAC=Y <br /> WASTE HAULER FORM <br />' TO BE CO" l.__ED 3's WASTE To SRWC 50fi6 <br /> PLEASE eTx_1: rr -LNCO���OZ ��=eDR—iS ;a— i0'i BE <br />' Waste Hauler Ccmpany Na.=e � � _ 1 t-�, , &-a_r 've�-_c_e Ca=ac_- <br /> Vehicle License No. Date Ker f �1 :.--ad #� <br /> Complete name, address, type, and quantity of waste aource(s below. Arsignature shall be <br />' obtained from a represe-tat• ve from each source, verifying the type and quantity stated. <br /> If more than four sour Ys � the waste load, attach additional forms. Random verlf-cation <br /> vz11 be ]Lade SRW n <br />' 1. Name: <br /> Address.--- <br /> Phone <br /> ddress:Phone No. : ( } 7 <br /> Waste Type. ar__ty: 2 gal. <br />' Signature: z� <br /> Date: it Ti.•ne: ZI!L `A.M. P.H. <br /> Within Stockton city 1._=_ts? Yes No <br /> t <br /> i <br /> t <br /> S <br /> Allowable Waste Type: Place applicable number 3-n space provided above. <br /> 1. Residential Septage" 2, Portable Toilet' 3. Restatirant Grease Interceptor 4. Special <br /> Disharge" <br /> 'sgp.h a-M WX be rW=-cd;b.a k=b= wd mwam� p= sbaa be mdamrcd <br /> A 3Qaeu1 Pa=rt must be ksed and>pprovad br SRWCP before dsaebane a aacwcd <br /> I, the below named waste hat ler, declare urder ena'_tr of per)ury, tnat to tie best of my <br /> knowledge I have accura=elr described the type, q,_art_ty, and source of allwaamea r.nscn I <br /> now request to dispose of at the SRWCF. I fustier ceclare, tZder penalty or: per�urr, that <br /> I was personally informed by the owner, owner's agent, az cccuaant! of the prat,ertr where <br /> this waste was received or have personal kncwledce, tna= t._s waste contains crly <br /> residential septage or grease, or in the case of a Special Pe-=_t, is not raza.rdcus and <br /> does not exceed prevzous'_y a-therized 1--its, a3 c-er Pretreat=er_/Sctrce Co-:trol <br /> requirements_ I also de_lare, urder penalty of _er�_r t-at tre truck(z) used to <br /> transport tnis waste was fre-e of all sate;jals C_a_acte,ized bt, la- as a razartous caste <br /> or substance at the ti=e of said use I an a4ara of _^e cc~d`viors a,d rec __-�en•s of <br /> — <br /> the Waste Hauler Per=-t P'- this, I understand -at fa=lure accurateli des=rite the <br /> FRove information or failure to comply with mr maste -:a=ler Perm.Lt a,d/or ars ap_pl_zable <br /> WCF regulation, may rest-it in the immediate s�,spe^sten c`) m; l <br /> Waste Hager �prmt and/or <br /> other penalties as may be allowed by law. /� 1 <br /> Waste Hauler S_grataxe / <br />