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nuu/ !3!LUI urn1 ui.ji rm DCvu1111 PAX NO 1MObUbb FAR <br /> i <br /> .a <br /> 1 <br /> i <br /> TO BE COMPLETED BY- WASTE HAULER BEFORE ENTRY TO SRWCF. 31739 <br /> Waste Hauler Company Name Lr_ vehicle Capacity ,?� <br /> vehicle License No. 2 Zley # Load ,# <br /> Y_-..._ <br /> Cosdpiete ansa, address, tYm, and ijuantity of waste sowrce(s) below. a signature shall be <br /> obtained from a representative from each source, verifying the type and quantity stated. <br /> If more th— four sources in the waste load; attach additional forms. Pandom verification <br /> will be made by BRMF. <br /> 1, Name: f "� <br /> Addresst <br /> I <br /> Phone No.: <br /> Waste 2`7fPa= �: ! -• Quantity: e-r1G gal. <br /> Signatures <br /> Date: lA ! / Tim �i A.x.. . <br /> within Stockton city limits? Bic } <br /> J <br /> f <br /> law 16 Waste Type: Place applicable number in epees pl+py,ided above. <br /> Diaharge <br /> 1. Residential. Neptage• 1. portable Toilet' 3. Restaurant Greaee Interceptor 4. Special <br /> .�gat ,tiu a �d ceuamie!ate be ; <br /> A 8paeid Pbm1 o"k oomp#md,ed-$goo, yj 3lnWCp�orc 4MeP u do.od <br /> 1, the below named waste hauler, declare under penalty or perjury, that to the best of my <br /> knowledge I have accurately described the type. 9"Otity, and source of all wastes which I <br /> now request to dispose of at the SRMF. I further declare, under penalty of perjury, that <br /> I wad personally informed by the owner, owner•a agent, or occupants of the -property where <br /> this Waste was received or have personal knowledge, that this •caste 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, ander 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 Ra�uler 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 suapenaion of My waste Hauler Permit and/or <br /> other penalties as may be allowed by law. =7 <br /> Waste Hauler Signature ,_ .• . /!� f ` <br /> r. <br /> i <br /> f <br />