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Jun 121207:34a Parrish & Sons Inc 209-465-5736 p.4 <br /> STOCKTON REGIONAAL WASTEWATER CONTROL FACILITY <br /> WASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 34 Sn72 <br /> PLPASP PRXNT AND PRHSS HARD. INCOMPEM OR H-1 PnOLH FORMS WML NOT SR ACCEFr ). - <br /> Waste Hauler Company Name Vehicle Capacity (— ` <br /> a <br /> Vehicle License I Date Rey # Load f <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 in the waste load; attach additional forms. Random verification <br /> will be made by SRWCF. pp ii <br /> 1. Name: '�-T- 'tG.V��C.S 2. Name: � l..- T <br /> Address: N3 vo Address: <br /> �� %y `jIZX..kTDn Zip -tE-Lj�Z Zip 7 <br /> Phone No. : Phone No. : (Z C.(.Q LA T-? - � <br /> Waste Type:"�`'"I Qu t' y: i;7 M gal. Waste Type: uant'tgal. <br /> SignatCure: -�(�'� Signature: <br /> Date: Time: ' FA.M. <br /> P.M. Date: - - \Z. Time: A.M. P.M.Within Stockton city limits? No Within Stockton city limits? Yes No <br /> 3. Name: — 4. Name: <br /> Address: Address: <br /> Zip Zip <br /> Phone No. : ( ) Phone NO. : ( ) <br /> Waste Type: Quantity: gal. Waste Type: Quantity: gal. <br /> Signature: Signature: <br /> Date: Time: A.M. P.M. Date: Time: A.M. P.M. <br /> Within Stockton city limits? Yes No Within Stockton city limits? Y�����eeIIIs No <br /> TOTAL QUANTITY (All Sources) : gal. <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage' 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. Special <br /> Disharge- <br /> 'Sigmnvca.21 o b.mq,ired,ba bcxiw=d rc pwublc pc,sm xrm be M K.ud. <br /> A Sp...1 Pmu h mux be campk"and app..d by SRWCF bcfmc dis'Lsrgc is dloacd. <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, isnothazardous and <br /> dose not exceed previously authorized limits, as per Pretreatment/Source Control <br /> requirements. I also declare, under penalty of perjury, that the truckle) 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 /> above information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> SRWCF regulation, may result in the immediate suspension o my Wa a Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br /> 'Received Time"Jun. 12• 2012 7: 30M No, 0183 <br />