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MAY-19-2001 (SAT) 23: 45 P. 002/003
<br /> FROM FAX NO. Jul. 28 2003 12:28AM P1
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<br /> Brl.'.oOMPLETm.:;�1x,:,,WASTE. EnvLER• ,BE'oxl •:.ENTRY,'-To:'.SRwcF:_ 15149.
<br /> :�•, "'.,,•. .. '..•. •;. .:"•'• 'n.ra►an•rtttt�rs'�rpu�ss• 'no.'' oa Fo�wnr:ero'ra woc�'sa:. /. • •' • .
<br /> 'WaBte iatiX'or Coni any Diame'.i chicle Capaoity {
<br /> Yhic�Ia'L'ic�nac•1qo. tc ,� Load #•• '
<br /> w." t.a�pYeto.naaa;•.hd oaa,•;`typa', i=d quda.#ity qf, Walt iaoaz�corsl:•.belcw� A cignatvre shad be
<br /> 0)5*•;,,••� fres•a raptcaeatatirc..fraa'saeh• ot{s e'; verif3e3ng.iths:,typ&.•Lud •quzmtxty stated.
<br /> asoro,tif�a.four sotircon 'ia tb� rraato •load;''4ttach 'additional •form&.,;>Random.•verification .
<br /> will bo'aedn.-)aT SMCF-:
<br /> l. lvamc a Name z
<br /> - ,. Zig Zip
<br /> PhOnC 1$O.?( ' ) r1 Pham: NO.:
<br /> 1Pa,ate.Type: tityc�e0 al' waatd.Type Qu ity:; gal
<br /> 9:,� .';Si.gastur z �. � signatsxre'a' 1
<br /> Date? Time:, 11.�C: •P' t�. ,'Datrz , 11 Time. a_x, l.M.7. ,
<br /> wil2hin' S�acktmri'City''1'imft, 7 ,'Xoa No. Within Stockton'64tty limits3 Yea• : So'
<br /> 3..• Rst�wi 6. Namoz
<br /> a►ddr®sae ' Addroao:
<br /> ZIP,
<br /> " Phanc»04-'.� , ) . . Phoi o oft:.t
<br /> Waste Typ@s' Quaati ga1:l'. Waato ,TyI*, �4uaa�3ty:_•"_9a•
<br /> tY='
<br /> Signature: ... ' Signaturo•: '
<br /> Dates• Thio: :A:M. P.M. , Data:
<br /> Nithin &toektan:city 1'i2ztfth?. 'Y013* No Within-,Stockton city Iilnita? . Yeo Ho
<br /> TO'CAx.'QD7laT1!ITY (1111 'Sourco=)•t gal.
<br /> fir' ]ilYoirablei waste 'yjps:•Place'applicable number , 'ipace provides
<br /> ;I. lmaidential SeQtaga' ' 2. Portable Toilat� •3. Seataurant :Greaae• Intarceptar 4. Special
<br /> �. 1 AmaberWi�o�but
<br /> t"i•�Catim'and rciv—'W
<br /> P�O"+�aflbebdlryod.
<br /> !Y . —.k ftw.d}ass� 2•
<br /> ba 1 `7'•"•" sad" br SiCWOF,bclvta 4Labu�a u at{aoed.,,
<br /> • t tothe bQGt Of.M' ••I,, �hc•bcl'aw named,waste :hauler,•d:clarci 'ander 'pena4ltjr of perjury,.;the ' my'
<br /> ",;knowledge �']iavc accurately deacrikied'this type, quantity,':sad.'aaarco,'ot, all' wperj y ch'I
<br /> ,t now'requent to dielpone,of at",thq m>WCF. Z Further declare, under. 'panaltY 'of:'perjury, thot
<br /> I'�wp2e"poraoasl ly info'ra2ed by:,tke' Owner, cwnex'a agnntl, or.:.oCcupaz tv ot< the.property where
<br /> Chia waetc wan, received 6r'.bave`perc�onal ,kAdwiedo,•that'tin waste ccntai na_only
<br /> roaidaic�tial ceptiage Qr'greaae; or in.thi3 case of• 8 specie] wPeza►it; •J.ii'sax hazaitdoua 'and;'' '
<br /> doco -not excecd••prlcvioualy,'awthoi,,iied. limits,, a13',pei.Prctreatment/Souxcc Control „
<br /> raQu re. . =. I ,algo,'declare, uad'er:p'enalty''Of perjury,' that,the truck(s).'udcd to,
<br /> '�anapore thio.'waate' wao"frdo Of all :materiala'•characterized.by law as s hasardouo 'aaaCc
<br /> 'or ngbataLnca at tbQ time of bai.d' uac. . I•am 'aware ,ot the conditioite and' requi rd mento of
<br /> ths'Wasic• Haular'Permit: 'Further., 'I undbicwtand''thA-' fziluro to accurately describe,the
<br /> +�' ' .abF?vc'infortnati.pa ARr.2ailure to coMply with my Wantc•Hauler Permit and jor• any, apEl3 cable'
<br /> • ' SR-?CF :=agulation; ct may result La the immidiatauogahuicin Of,.*my 'Waste Hauler; P.exmit 'an ar
<br /> " 'ether pnnaatiea»as=Ay be allow ad15y lbw.
<br /> Wants Hgular•signature_' '»
<br /> '•,a. �1'CRKAYIv�PRItJTINO'C?ge1�ea+Cl:6!' ', '. � �. ...
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