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1 <br /> STOCKTON REGIONALWASTEWATER CONTROL FACILITY <br /> e WASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 38818 <br /> PLPASE PRINT AND PRESS HARD. INCOMPLETE OR n*EOMLE PORMS WILL NOT DE ACCEPTED., <br /> Waste Hauler Company Name*;,al -- ✓� rye=t` Vehicle,.Capacity <br /> Vehicle License NO.—7 i ��;�`� 5 Date ] ct \� Rey a1 �;. ~} Load d <br /> Complete name, address, type, and quantity of waste source(s) below. A signature shall be <br /> 1 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. <br /> 1. Name- <br /> Address:. <br /> ame:Address: <br /> Phone No.`: <br /> Waste Type:YP - Quantity: ,,}. � gal. <br /> ' Signature <br /> Date Time: A.M. P.M. <br /> Within Stockton city limits? 7Ce e' No <br /> d � <br /> Ile <br /> Allowable Waste Types Place applicable number in space provided above. <br /> 1. Residential Septage' 2. Portable Toilet. 3. Restaurant Grease Interceptor 4. Special <br /> Disharge" <br /> -Seuft +evil m be eequLmd,bot Iocatm and mspouibie penin sbal be iodicaled. <br /> ' A Special Permit must be complcted and approved by SRWCF betwe dimbaMe is&Roved. <br /> I, the below named waste hauler, declare under penalty of perjury, that to the beet of my <br /> knowledge I have accurately described the type, quantity, and source of all wastes which I <br /> tnow request to dispose of at the SRWCF. I further declare, under penalty of perjury, 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 n(A 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 /> or substance at the time of said use. I am aware of the conditions and requirements of <br /> the Waste Hauler 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 suspension of my Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> 1 Waste Hauler Signature_ A <br />