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v <br /> STOCKTON REGIONAL WASTEWATER CONTROL FACILITY <br /> v WASTE ,HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 00165 <br /> PLPASB"2U AND PRESS HARD wcoMPI=oR ILLP MIF PORM WiL[.NOT BS ACCEPTED <br /> Waste Hauler Company Name i f jq i e �� ��_ _1, Vehicle Capacity <br /> Vehicle License No. 44;,-3 -i�/ Date —7-; -,� Key # 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 /> If more than four sources in the waste load; attach additional forms. Random verification <br /> will be made by SRWCF. k <br /> 1. Name: 0 e) <br /> Address; o I- LAD - /// el -, W4 <br /> ? r.;-- 7,� .�- �'1n Zip r r-20K� <br /> Phone No.: ( ) - <br /> Waste Type: /C1 Quantity: S()d gal. <br /> Signature: ^ <br /> Date: -;7-- <br /> ,7-37 9 Time: �S` d�Ml P.M. <br /> Within Stockt n city limits? Yes _No <br /> s <br /> J f <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 /> S*Msmca win not be n vmmd.but kmabw and msponw'ble pen=sW be mdxat d -- <br /> A <br /> A Sp—d Pamd mud be c=WJc ed and approved by SRWCF befwc dacb&%o is a kmW - <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'ofYperjury, 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 o- <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` hazaidcis waste <br /> or"substance- at_the,time of said use., I am-aware of the aonditions 'and-requiii"ents of <br /> the,Waste, Hauler-Permit. Further, I understand-that, failure to+ accurately describe the <br /> above`infozmation or failure to-comply with my Waster:Hauler Permit=-and/or any applicable <br /> SRWCF,­regulatLon, 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 />