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T_ '' F Y <br /> STOCKTOREGION AI. ��.S���.�� .ITER CO�+TTROL :�C3iTF <br /> WASTE HAULER _M_-_NIFEST FORM <br /> TO BE CC;-'.____._T - BY W,*A ST- ,;���c BEFORE- =—TRY TC SR C- 5067 <br /> �� <br /> PL=AS£PL1 �vp rd1RD X�CU�'�"_OR :_?C�ai_ =O;L s A=NOT 3c 1CC_z=__J <br /> \ ���Waste Hauler Company Na-e , u , Vea_cwe Cacac_t r <br />' Vehicle License No. Date # �`�I--ad t <br /> Complete name, address, type, a-nd quantity of waste source(s) below. A signature shall be <br /> obtained fro= a representative fro= each source, verifying the type and quantity stated. <br />' If more than four sources L. the waste load, attach addit�oaal fors. Random verification <br /> will be =Lade by SRWCP. <br /> r <br />' 1. Name. .9enaL&_;� C7 <br /> Address:-- <br /> Z 3.=) <br /> ddress: Zip <br /> Phone No. ; ( = (0:7 <br /> Waste Type• - -- �gal. <br /> Signature: �- � `- <br />' Date: . / A.H. P.H. <br /> Within Stockton city 1_=__s' Yes No �! <br /> s � <br /> t <br /> I <br /> 1 <br /> U_s 1 a a�• _ _ _ <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 /> sq—ft—xM mt be reg=—.,but So—a mod Fmk pa=s=sh.9 6e ma—m-4 <br /> A Spo: l P=ftvA mums be eampk-d and mpp-w d by SLWCF bet=dear++':e is aacwcd <br /> I, the below named waste ha,-Ie--, declare tinder pe-altr of per]u=y, tna= to _ne best of my <br /> knowledge I have accurately described the type, cuart_ty, and source of a-1 wastes which I <br /> now request to dispose of a= the SRWCF. I f,:=tner declare, ender penalty cf zer3ur"y, that <br /> I was personally informed by the owner, owner' s agent, o; occupants of the proner•ty where <br /> this waste was received or have personal .cnewledre, tnat tnss waste co-ta=ns only <br /> residential septage or grease, or in the case e! a Scecial Peet, is rct raca;dous and <br /> does not exceed previously a_thorzzed limits, as cer� Pretreatment/source Cc-trcl <br /> requirements. I also dec_are, under penalty c- per;ury, that t,ne t_..cK( s) -sad to <br /> transport this waste was Free of all mater-a-s c;a;acterzzed by la« as a nazardous waste <br />' or substance at the t.re of said use. _T a.- a-are c= One cend_t_o^s and recr_remezts of <br /> the Waste Hauler Permit. ~=;:er, I understated --a- zailure to acclratelLL aescribe the <br /> above information or failure to comply with mr waste hauler Pe—mit and/or anf applicable <br /> RWCF regulation, may result in the immediate suspension o�r�c� Waste '?aster Permit and/or <br /> other penalties as may be allowed by law. �. <br /> ;Taste Hauler Signature � ) <br />