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1 <br /> STOCKTON REGIONAL WASTEVY'ATER CONTROL F A CL_ITY <br /> WASTE HAULER NLA-NNIFEST FORM <br />' TO B: CC.v-7L'= BY WASTE. SEF0R-EE ..NTRZ TC a-('raC-. 5069 <br /> FI ZAZE 'LkRi 'Z'C'0 0 i M—'= =0E-V-5 47: tiOT 3 F -,C <br /> Waste Faller company bazne Qf'y Ca-ac_ty � �7 <br />' Vehicle License No. Date -cad # <br /> Complete nam=e, address, type, a=d quantity of waste source(x) below A signature shall be <br />' obtained from a representative from each source, verifying the type and quantity stated. <br /> If more than four sources 2n the waste load; attach additional forms. Random verification <br /> will be stades by SRWCF. <br /> 1. Name: <br /> Address: <br /> zip <br /> Phone No. : ( ) <br /> Waste Type: Q,.a y: gal. <br /> Signature.- <br /> Date: <br /> ignature:Date: Ij - 2.2' �1Tzrae: A.H_ P.M. <br /> Within Stockton city 1. _ts? Yes Pio <br /> 1 � <br /> 1 � <br /> ` 4 i <br /> -� • <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> I. Residential Septage' 2. Portable Toilet' 3 Restaurant Grease Interceptor 4. Special <br /> Dzsharge t <br /> Seeaacaea w M aot be rcq=rcd,baa Samoan,od rccpa¢obk peram W%LU be z„iw.&CCd <br /> -A 9ponal Pett must be eampk%M apd zpprwcd b+SRWCF before dmcharge a aacwtd <br /> I, the below named waste haL,er, declare under =enal-y of per)ury, =.at oa tl a best of =v <br /> t knowledge I have accurately described the type, c-uanti:._. , and source of all wastes which I <br /> now request to dispose of a= the SRWCF. I Turner declare, tinder pena'_tr of per3ury, that <br /> I was personally informed by the owner, owner's agent, or occupants of t,e property where <br /> this waste was received or have personal knowledge, that t.^._s ,ias}e ccn aLns only <br />' residential septage or grease, or in the case of a S1ec_alPerm_t, is moo= hazardous and <br /> z <br /> does not exceed previot_sly a_thcrzed 1-nits, as p-er Prerreatme-t/Source Cc-taol <br /> requirements. I also decla;e, t:-der penalty :_ :er1 -.at the -'CK( S) ..sed to <br /> transport this waste was free of all araterials c-a_ac_er-zed by la- as a -azar-'ous .+aste <br />' or substance at the time of said use. I an apare of _^e zor -t_crs a^d re.;.._remenzs of <br /> the Waste Hauler Permit. .:^er, I ur•ders4ar c 'tea;. fa__U-e t),- acc_rate'_ r uascrlbe the <br /> above information or failure to comply witri my waste -:auler P9"it a^d,Ior a- " appl_cable <br /> SRWCF regulation, may result in the immediate s,s ens Yo^ o= cry Waste Ha-ler Peet and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signatu / �-� <br />