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STOCKTON REGIONAL WASTEWATER CONTROL FACILITY WASTE HAULER MANIFEST FORM TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 71923 PLEASE PRINT AND Pt SS HARD..IN OMPLETE O ILLEGIBLE FORMS WILL NOT BE ACCEPTED. Waste Hauler Company Name �uS _O Vehicle Capacity 3 C] Vehicle License No. 7.3 6 �'%� Date Key # %� Load # Complete name, address, representative from each load; attach additional for 1. Name: (---' _� -/4 L 5 Address: , � eAa R4 4 L de LA �� - zip Phone No.:( ) Waste Type: M Generator Signature: -t` pT- J type, and quantity of waste source(s) below. A signature shall be obtained from a source, verifying the type and quantity stated. If more than four sources ste ms. Random verification will be made by SRWCF. �p Date:�-� ] -, ime: , �S A.M. P.N Within Stockton city limits? Yes 3. Name Address: Zip Phone No.:( ) Waste Type: Quantity: gal. Generator Signature: Date: Time: A.M. P.M. Within Stockton city limits? Yes No 2. Name Address: k�can �A_ zip Phone No.:( ) V - �{- 's62 Waste Type: Quantity.,oAtw gal. Generator Signature: Date: - - Time: Ct' A.M. M. Within Stockton city limits? Yes No 4. Name, Address: Phone No.: ( )_ Waste Type: Generator Signature: Date: Quantity: gal. Time: A.M. P.M. Within Stockton city limits? Yes No TOTAL QUANTITY (ALL Sources): J gal. Allowable Waste Type: Place applicable number in space provided above. 1. Residential Septage 2. Portable Toilet* 3. Restaurant Grease Interceptor 4. Special Discharge - `Signature will not be required, but location and responsible person shall be indicated. ""A Special Permit must be completed and approved by SRWCF before discharge is allowed. I, the below named waste hauler, declare under penalty of perjury, that to the best of my knowledge I have accurately described the type, quantity, and source of all wastes which I now request to dispose of at the SRWCF. I further declare, under penalty of perjury, that I was personally informed by the owner, owner's agent, or occupants of the property where this waste was received or have personal knowledge, that this waste contains only residential septage or grease, or in the case of a Special Permit, is not hazardous and does not exceed previously authorized limits, as per Pretreatment/Source Control requirements. I also declare, under penalty of perjury, that the truck(s) used to transport this waste was free of all materials characterized by law as a hazardous waste or substance at the time of said use. I am aware of the conditions and requirements of the Waste Hauler Permit. Further, I understand that failure to accurately describe the above information or failure to comply with my Waste Hauler Permit and/or any applicable SRWCF regulation, may result in the immediate suspension of my Waste Hauler Permit and/or other penalties as may be allowed by law. Dump Date ",J and Time 1 of discharge at SRWCF_ Waste Hauler Signature ::ODMAIGRPWISEICOS.MUD.MUD_Library:133669.1 Revised 2/19/15