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r <br /> STOOKTO.N RE GION;L W ASTEV� A f ER CONTROL ROL Fz,CLI T Y <br /> WASTE HAULER ML-�N'IFEST FORM <br />' TO BE COMPT-_-E D BY WASTEL= = �::0 W,TR� TO ERWC.F . 5103 <br /> Ft.ZEASE PR_ tti:?RFSS HA- �COke —OR j FO;Z�i4 NOT 32 1CC.:7—=7 <br /> —7 l <br /> 1 Haste Hauler Compm <br /> anf Nae Ve`t_c_e CaPac__ r � - � - <br /> Ver.Lcle ?_cerise No. /,c. Date J del # _:,ad if , <br /> Camglete name, address, type, a=d quantity of waste source(x) below A s_gnature shall be <br /> 1 obtained frog a represeatat!ve frau each soLrce, ver_fying the type and quantity stated. <br /> If more than four sources z: the waste load, attach additional for-as. Random verification <br /> will be made by SRWCP. <br /> T4 <br /> 1 'Address: <br /> Address: <br /> Phone No- : ( <br />' Waste Type: / Qua^-_=y i 7 _ gal. <br /> Signature: <br /> 1 Date: Time: A.M. P M <br /> Within Stockton city 1=__s' Yes �NJ <br /> 1 <br /> t <br /> 1 <br /> 1 Allowable Waste Type: Place applicable nu=ber 1.n space provided above. <br /> 1. Residential Septage' 2. Portable Toilet' 3 ?estaurant Grease Interceptcr 4. Soec_al <br /> Disharge" <br /> 1 'SWMLC=a WM pot be xequumd,but kraavi nd sea I Jc Pcrwn dwn be od—,1,A <br /> A 3P=ULi Permit must be ecu 7F k&Cd Md gTrwad try SRWCF bd 0M dacb&MC o allw cd <br /> 1, the below named waste hauler, declare urder pe^alty of per3ury, =^ati to t:e best of wr <br /> knowledge I have accurately described the t r-pe, quanntity, -aid soLrce of 3_1 wastes ,mica. <br /> mica I <br /> now request to dispose of at the SRWCF. I fL.=-e= dec_are, unser to^alzj of ger]L^t, that <br /> I was personally informed by the owner, ow^e_' s agent, or occupants o. =^e prc:=er-ty where <br /> this waste was received or have personal knc-ledge, teat th_s waame conta-ns o-ly <br />' residential septage or grease, or in the case c_` a Sgeciai Pe=_t, is .-V <br /> ^o_ -ataous and <br /> Goes not exceed previously a-=hor,zed 1_-nits, a3 =_e= Pretreatment/s::,,__Yce corm-=1 <br /> requirements. I also declare, under penal_~ of zer�Lrl , !:iat tre ___zk� s) ;.sed to <br /> transport this .caste was free of a'_1 r•ater_3_s _-aracter_, zed o_ -a- as a -azar:ous .caste <br /> 1 <br /> ors <br /> at the t=e o: said use. i a:- a-are cf t-esa-id ram =_ <br /> _rmeata of <br /> the Waste Hauler Permit :`=rmher, I Lndersta-u -3_ =V <br /> `a_lure ^, ac. yratz_ r des_rzbe the <br /> above information or failLre to comply «its mr masts :auler Per--it a^d/cr an. anal-cable <br /> RWCF regulation, may result in the immediate sas:e--sion of my waste haler Pe--=—, t and/or <br /> other penalties as may be allowed by law. <br /> waste Hauler Sig^ature_ _ - - i ✓ze- sem_ <br /> 1 <br />