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>■ <br /> <br />• - r <br />38818 <br />I <br />gal.M- <br />il <br />4. Special <br />I <br />STOCKTON REGIONAL WASTEWATER CONTROL FACILITY <br />WASTE HAULER MANIFEST, FORM <br />A.M. P.M. <br />NO <br />V; v I th 7 <br />zip^r^r <br />Allowable Waste Type: Place applicable nunber in space provided above* <br />1. Residential Septage 2. Portable Toilet’ 3. Restaurant Grease Interceptor <br />Dxsharge e <br />'jigaaiOKa win M be required, but locatkn tod retpauMble pawn dwO be indicttotL <br />” A Sped*! Permit mutt be eanpfaed tod tpprcved by SRWCF before ditchi^e b eDowed. <br />HE "r— * - —;thia waste was received or have personal knowledge, that this waste contains only <br />a®2rial se?ta9e or grease, or in the case of a Special Permit, is no£ 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 />tL w«r«nSe ?t fcSe o£ said U8e* 1 ““ aware of the conditions and requirements of <br />?t? HauJ?r Permit. Further, I.understand that failure to accurately describe the <br />SRWCF r2™i?tti«n Or failu5® c?mP}y with my Waste Hauler Permit and/or any applicable <br />' y result in the immediate suspension of my Waste Hauler Permit and/or <br />other penalties as may be allowed by law. , <br />H / z7 /9 Waste Hauler Signatur <br />(/ <br />TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. <br />PLEASE PRINT AND PRESS HARD. INCOMPLETE OR ILLEGIBLE FORMS WILL NOT BE ACCEPTED. <br />Waste Hauler Company NameV^Xc A - 2 cyA eC'Vehicle. Capacity <br />Vehicle License No.^ Hz^.< JL Date 3 Cm \\ Key # \ A Load # <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 />^22 byUSRWCprCeS tho *aste loa<3; additional forms. Random verification <br />1. Name: A <br />Address: \ (j> 5^0^ NAr <br />V- C <br />Phone No.:( . ) \ <br />Waste Type; \ Quantity:\ ^<0 <br />Signature: ' ^7 <br />Date: | ■ \ ■ Time: ,3 , <br />Within Stockton city limits? >¥es^