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3'—,gt r f 3`-�"r �, `' 7�a'a*' ZZ �r` r F�'�%�,.+1,�0 ,f..' C f }�"_>•�4 Yom' > 'w yP_ R„ -,� <br /> a �•ter - sus ;.,:xh s y - �' �'�r me���'-;ar,. �a Y}..- <br /> CONTROL FACII Y <br /> O L <br /> �� arI01 , ; .1�,� r 4 ; <br /> fasir f �.'�.�� �. FORM <br /> ,J s, <br /> -' -TO BE, COMPLETED-BYE WASTE HAULER BEFORE ENTRY TO SRWCF. O S <br /> . PLF.49E PRII1P AND PRESS HARD lNC'OMnL OR MLWU LE FORMS wum NOT BE Acca r D <br /> Waste Hauler Company=Naive r r <� 1 3 Vehicle Capacity <br /> Vehicle License-No. 1'6 I - Date Z—,- Key # Load 0 <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 sore than four sources in the waste load; attach additional forms. Random verification <br /> will be made by sRWCF. ! <br /> 1. Name: oS <br /> Address: i UJ �'�R 0 761 LU A- y <br /> zip /� 5-?O� i <br /> Phone No. : ( ) `j J <br /> Waste Type: K7` Quantity: _gal. <br /> Signature: <br /> Date: - ,P5 Time: A.M. P.M. <br /> Within Stockton city limits? Yes No <br />- ' 4 <br /> I <br /> -f <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> r 1. ResidentialSeptage' _2. Portable Toilet' 3. Restaurant Grease- Interceptor 4. Special <br /> Disharge" _ - <br /> t, 89m1U s wM o t be roqu=d,bum locsbw m&nmpa ambo pavan dmB be mdrAted _ Y <br /> r A Specsal Pamst mou be campleted and approved by SRWCF Wom dw me to aibwod _ - <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, ownei'i:agent, or occupants of the property where <br /> r this waste was received or have personal knowledge,- that this waste contains only- , <br /> residential septa4e, 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; under penalty of perjury, that the truck(s)- used to <br /> cM <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•r-Further,��I,3unde-rstand-thiE, failure to accurately describe the <br /> r - above information ox: failure(to;6ompl3�,with my Waste=Hauler Permit and/oro atiytiapplicable- <br /> SRWCF regulation; may, result!in,the immediate suspension of my Waste Hauler, Permit= shd/or• _ y <br /> other-penalties as may be allowed by law.- <br /> Waste <br /> aw.Waste Hauler'Signature - - -; - <br />