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STOCKTON i%=GIO --ItL WASTEWATER CUi,4TR0L FACS=Y <br /> WASTE I-LkU ER -%f4N, gEST FORM <br />' TO BE Bf WASTE =ELR BEFORE ENT—Ry TO SRWC-. 5101 <br /> POSE P,Z ti: RZ-&S S.hU elCIO�Ie Gni a__z-C.BLZ.VOe;Lw il- dT 8 C'Z-7= <br /> caste Hauler C:mparr NaY.e / -- - _ - Venicle Capac_= —>--� <br />' ven_cle License No. Date --- - -<ey # r Lcad if <br /> Complete name, address, type, and quantity of waste source(s) 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 inthe waste load; attach additional forms itandoa verificatsoa <br /> will be wade by SRWCF. <br /> 1. Name. <br /> =.� <br /> Add-ress: ' <br /> Phone No. : ( <br />' Waste Type: , ! quantity: gal. <br /> Signature: 777 j~ <br />' Date: / " - _ Time: / A.M. <br /> Within Stockton city 1L:--its? Yes /No <br /> e ' A <br />' J l s <br /> 1 L <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage" 2. Portable Toilet' 3. Restaurant Grease _nterceptcr 4. Special <br /> Disharge" <br /> SVMaaaa WM as be requwod,bss locubca mad rt5 ie prrxn■h R be wdr-c+ <br /> A SpccW Permit n uac be mmpkud and appm` b7 SRWC,F befog d=b&Mc n&Zcwa3 <br /> I, the below named waste hauler, declare under _enalty of per)ur-r, t-at to t-e best of my <br /> knowledge I have accurately described thetype, cuantity, and source of a_1 -astes such I <br />' now request to dispose of at the SRWCF. I fu_�aer declare, under penalty of per3ur'y, that <br /> I was personally informed by the owner, owner' s ager--, or occupants cf tie prcterty .There <br /> this waste was received or have personal knowledge, t`:at this waste coma_^.s crly <br /> residential septage or grease, or in the case of a Snecia'_ Perm_t, is not naza;dcus and <br />' does not exceed previously authorized 13-wits, as te= Pretreatment/Sci-rce Cortacl <br /> requirements. I also declare, under penalty of per3urr, that the t=-ck( s) used to <br /> transport this waste was free of all mater_als cnaracterized by la.. as a -aza==ous caste <br /> or substance at the time of said Lse. I am aaa-e of t'�e conditions a-d ;e---L._reme*ita of <br /> ' the Waste Hauler Petit .=-her, I urdersta.,d t-at failsre to acc..ratel: deszribe the <br /> above information or fa-, lure to comply with m_r haste Hauler Pezmit a-d/cr a- applicable <br /> RWCF regulation, may result _n t'ie 1 ediate suspension of my Waste ra .ler ?emit and/or <br /> ther penalties as may h-e allowed by law. <br /> s.aste hauler Signature <br /> 1 <br />