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� r <br /> T 4 � <br /> Sro roN Rtbiwm w rEw� co op. FAcn v <br /> WASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5023 <br /> " PI1�AW PJMa AND PRFs}BARD 24COMPLM OR IIX.E[M FORMS WU.L Nor BE ACCEPTED <br /> Waste Hauler Company NamVehicle Capacity_�,/%J <br /> Vehicle License No. ' - Date L/2e- L1—Key # 1 7 Load # <br /> Complete name, address, type, and quantity of p mate xource(s) below. A signature shall be <br /> obtained from a representative fron each -source, verifying tlio- typeand quantity stated. <br /> If more than four sources in the waste load; attach additional forms. Random Iverification <br /> will be made by SRWCF. <br /> I. Name: J� <br /> Address: <br /> Zip p ; <br /> Phone No.: ( <br /> Waste Type: �� Quant ity;— gal.-` <br /> Signature: 4. <br /> Date: 0Z <br /> Wit4in Stockton city, limits? Yes , <br /> 6 <br /> J � <br /> i <br /> Allowable Waste Types Place applicable auab r iii- space provided above. <br /> 1. Residential Septagie 2. Portable Toilet ,3.-Restaurant Grease Interceptor 4. Special <br /> Disharge- <br /> swmrw VM set be an med,but S =mm amd ale perm=shall be uxbcwd 1 <br /> A spmal PM[d most be oampbftd and Mrmwed by SRWCF W=&wharge n a 11 w -- <br /> ;' � v,rte �...�,.0 r..., -•---+ r <br /> I, the below named waste hauler, declare undeVypeaity-of-perjy;that to the best of my <br /> knowledge I have accurately described the tom, 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-9f 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 ok 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-despribe the <br /> above information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> SRWCF regulation, may resultrin the Immediate suspension of my Waste Hauler.Permit and/or <br /> other penalties as may be allowed by law. , <br /> - waste Hauler Sicnature -1 <br /> - _ z <br />