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STOCKTON REGIO.AL WAS71EWATER CO----,-TROL FAC-=r Y <br /> 'WASTE HAULER INLkNTIFEST FORM <br /> TO SL CG*EPLE---D BY WASTEE :"NTP-- TC S-ZWC 5102 <br /> P'.E-k.SE n.'4: 4h1-�? %SK -:-k_�...7 ycckl"— OR C3I_-ro,'Z10 k": --1,C'i 3H 4 <br /> .7aa a Haller ccmpa;,y t�a.�e t- .--� ri �~ - - -- - - -Ver_cle Ca_a___ <br /> Vehicle L.cenge Na. _ Jaye - far if =cac <br /> Camplete name, address, type, �.d quantity of waste source(s) below A s,gnature shall be <br /> obtained from a representat_ve from each ses.rce, verifying the type ayd quantity stated. <br /> If nor* than four sources i-= the waste load; attach additional for..s Razidca verification <br /> will be xadaby SRrFCF. <br /> 1. Name: J r1 <br /> Address• <br /> Zip <br /> Phone No. : ( ) x `7 <br /> Waste Type: - � � gal. <br /> Signature- � 4:~ <br /> Date: �-/ = ll Time: =f A.M. 'p H <br />' Within Stockton city t=its? Yes (NaPA- <br /> � f <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. ResidentLal Septage' 2. Portable Toilet' 3 ;restaurant crease Interceptor 4. Special <br /> Di.sharge- <br /> Se es wM not be rW=-Pd,boa krsaoo wd r=9x= 2we pasrn MAD be <br /> `A SP=Li Permit wu4 be oompieW and mod br SRaCF 0 LEo+.d <br /> 11, the below named waste ha,,ler, declare under penalty cf ner}ury, 4^a- tc the best of my <br /> knowledge I have accurately descried the type, quant=ty, and sct,rce c' atl .castes which I <br /> now request to dispose of at the SAWCF_ : fa-t-er declare, under persalt_ of per)ury, that <br /> twas personally informed by t.a owner, owners agert, ar occupants of tie Property where <br /> his waste was received or have personal knowledge, that tnis waste cm-=a-ns only <br /> residential, septage or grease, or in the case of a Special Pez--=..t, is -. ,aza,dous and <br /> does not exceed previously authorized 1:-nits, as P?r Pretreatme^t/Sc tce rc-tr l <br /> tequireraents. I also declare, -rider penalty cf =eta wry, =ham tr e t__=,c s , -sec to <br /> rans-part this waste was free of a?1 mater.als clarz„=__zed n, ,a.r as a "azardaus waste <br /> or substance at the time of saic! use. I a-m aware c; :-e a--o rez-.,_rements of <br /> he Waste :hauler Perm-t . ..rthe_, : understand =,mat fa..l.,.re to acczratF tescrLbe the <br /> ove information or fail,-re to comply with my haste -Laufer Pe=-t aoclicabl.e <br /> WCF regulation, may result in the ,YmedLate' s-z ersic:� of mi waste �a_'_e= 2e Lt and/or <br /> r penalties as may be allowed by lass. <br /> Waste Hauler S_nature <br />