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' 3 <br /> STOCKTON REGIONAL WASTEWATER CONTROL FACI `Y l <br /> WASTE HACK LER MANIMST FORM v <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5022 <br /> PLE 'M PRM AND PRESS HARD 24COMMZM OR n T_v_rnn....'.,.*'FORM WILL NOT BE ACCMM <br /> Waste Hauler Company Name 1,X ,.! Vehicle Capacity <br /> Vehicle License No. !j' ,y/j 3�� Date Key # l ? Load # <br /> complete name, address, type, and quantity of waste source s) below. A signature shall be <br /> obtalned from a representative from each source, verifying the type and quantity stated. <br /> If more than four sources in the waste load; attach addztsonal forms. Random verification <br /> will be Stade by SRWCF. <br /> I. Name: ' �u <br /> Address: <br /> zip 9i <br /> Phone No <br /> . ; � <br /> Waste Type; <br /> Signature: <br /> Date_ Time: A.M. P.M. <br /> Within Stockton city limits? Yes No <br /> J [ <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> I. Residential Septage` 2. Portable Toilet` 3. Restaurant Grease Interceptor 4. Special <br /> Dishargd' _ <br /> swuxu=WM an be mgwrod,but Iecmm and aSPO= &Pam ab.R be odw.a txL <br /> A Spend Pamd nmK be c*Whged and approved by MWGP betme dudmV n Silos W <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 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 <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 /> Mabove information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> WCF regulation, may result in the immediate suspension of my Waste Hauler Permit and/or <br /> her penalties as may be allowed by law. <br /> Waste Hauler Signature <br />