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STOOUON REGIONAL WASTEWATER CONTROL FAcnxry <br /> n . ; WASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5021 <br /> PiE&SE PRINT AND PRESS HARD DWOM ZM OR II.IMMM PORMS WML NOT BE ACCFPj'FD <br /> Waste Hauler Company Name y�j� iEij���P/1 vehicle Capacity � f 7 J <br /> Vehicle License No. bate 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 wa_pte load; attach additional forms. Random verification <br /> will be rade by SRWCF. <br /> 1. Name: W tZ rft,170'- <br /> Address: ,�,�, <br /> Z ip <br /> Phone No.. �7<y� <br /> Waste Type: Quantity: ;' 7< gal. <br /> Signature <br /> Date: Time: A.M. P.M. <br /> Within Stockton city limits? Yes ' No <br /> a <br /> 1 f <br /> Allowable Waste Type: Place applicable number sn space provided above. <br /> 1. Residential Septage' 2. Portable Toilet' 3. Restaurant Grease Interceptor '4. Special <br /> Disharge` .� <br /> Swunum w M not be ro*nm,but kcaam and ier; I ie pas=sW be sdxaccd. - <br /> A SpccW Peamd mint be=Wbed sod appiwod by SRWCF bcfaa dwdmp a allowed <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, owner's agent, or oc6upants 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 riot 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 /> RWCF regulation, 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 />