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STOCJ.TON REGIONAL WASTEWATER CONTROLFACILITY <br /> A WASTF, H' AAUI.ER A AMFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. <br /> PLEASE PRWr AN22r HARD WCOM L=OOMLE <br /> FORhIS WIM NOT BE ACCEP= .5061Waste Hauler Company Nam Vehicle Capacity <br /> i - zd <br /> Vehicle License No. Date r Key ,# � Load 0 <br /> f Complete name, address t <br /> ape, and quant ty 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 in the waste load; attach additional forms. Random verification <br /> will be made by SRWCF. <br /> I <br /> 1. Name: <br /> Address: <br /> Zip <br /> Phone No. : ( ) S"4) <br /> Waste Type: Quantity: gal. <br /> Signature: SP,45 _�.� <br /> Date: , � Time: A.M. P.M. <br /> Within Stockton city limits? Yes No <br /> �1 <br /> � f <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage Z.- Portable Toilet` 3. Restaurant Grease Interceptor 4. Special <br /> Disharge— T <br /> SW=uu=WHI nae be-qmred,but toe&tm and newa mbls perm ah&p be adramd <br /> A Sp=W Permit moa be oomplaled and appmed by SRWCF betas die a&towed <br /> I, the below named waste hauler, declare under penalty of perjury, that to the best of my <br /> knowledge I have accurately described the type, quantity, and source of all wastes which I <br /> now request to dispose of at the SRWCF. I further declare, under penalty of perjury, that <br /> I was personally informed by the owner, owner's agent, or occupants of the property where <br /> this waste was received or have personal knowledge, that this waste contains only <br /> residential septage or grease, or in the case of a Special Permit, is not hazardous and <br /> does not exceed previously authorized limits, as per Pretreatment/Source Control <br /> requirements. I also declare, under penalty of perjury, that the truck(s) used to <br /> transport this waste was free of all materials characterized by law as a hazardous waste <br /> or substance at the time of said use. I am aware of the conditions and requirements of <br /> the Waste Hauler Permit. Further, I understand that failure to accurately describe the <br /> w0above information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> RWCF xegulation, may result in the immediate suspension of my Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br />