ARCHIVED REPORTS_XR0008770 - Laserfiche WebLink

Home Browse Search

STOCKTON REGIONAL WASTEWATER CO,`,,RFROL FAC i Y WASTE HAliLER .%I_kN- EST FORM TO BE CQ;.�=T_ ='D 3Y W�.STE .�;�� E_Zp0_= �:�Y =C SRWC . 5068 FILZASE A.%C ?JZSS -Z.A2RD D,CC ki[r=S GR' --Z._0R,N5 4-a— NOT 3Z sC17–z_F—=_ Haste Hauler Company Naz_-e �p f1L.y , �.. , r ire^_c le Ca=aci �f�ll�r ' Vehicle License No. :,oad # Date �^ �L� "`� ..J fie✓ � l Complete name, address, type, and quantity of waste source(s) below. A signature shall be ' obtained from a representative from each source, verifying the type and quantity stated. If more than four sources z~ the waste load, attach additional fortis Random verification Kill be made by SxwCF. 1. Name. Address: r Zi n Z ' Phone No. : ) .9-3 S- 3 SIC `7 ! Waste Type- (21-an z_'ty gal. ' Signature: Date: Time: 3 C-) A.M. P.M Within Stockton city 1_u__s? Yes No l ' Allowable Waste Type: Place applicable number iII space provided above. 1. Residential Septage' 2 Portable Toilet' 3 Restaurant Grease Interceptor 4. Special Disharge- - 34;0& a WM aoc be requued,bLa kc—mod die pwj.=3hLa be.d=ato A 9Qemsa P==A mus[be ktod and mowed by SRWCP baw:diwhasic n allowed I, the below named waste hauler, declare under' _pe-a_tr cf per;u=r, t-at to t^e best of =1 knowledge I have accuratell described the type, ;mart_ty, and source of all wastes .hitt I now request to dispose of at the SRWCF. I rmner declare, under penalty o_ ger)ury, that I was personally informed by the owner, owner's agent, or ccc-pants of the property where this waste was received or have personal knowleage, t.-.at t—is waste contains only ' residential septage or grease, or in the case c_' a Special Pe Wit, is no, hazardous ar_d does not exceed previously a..thorized li--nits, as ren Pretreazme-t/S^Lrce Ccrtrcl requirements. I also declare, under penalty cf -e=; -: , t^at t-e _r1_1ck( 5) Lsed to transport this waste was Free of all mater_als c-a=_c_erized by _a- as a -azardous ..aste ' or substance at the time of said use. I am a..a_e ct the cord-t-ors a^d recr„yrements of the Waste Hauler Permit. Frr`her, I unaersta,d _-a_ _a_,lure tc a_c-rately cescribe the above information or fa-lure to comply with mr maste . ler Perm_t and/or ani apnl_ =able RWCF regulation, may result in the ir-mediate sL3pa^sicr of a� ?e�t was_e Haller it and/or other penalties as may be allowed- by laa. / • f n Waste Hauler Sig-t cu- '(-�