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i <br /> } <br /> L <br /> r <br /> McKTON REGIONAL wASTEwATER coNTRoL FACmY ' n <br /> 'BASTE HAULFR MANrmn FoRm <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5024 <br /> PLEAS PnTr"D P"m mum MOP-m=oR a Fames Pona waL rro r B8 wccEnm <br /> Waste Hauler Company Mame 9 11;1,9 Vehicle Capacity <br /> Vehicle License No. �/,-) C Date xey # 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 foul sources in the waste load; attach additional forms. Random verification <br /> will be made by SRWCF. <br /> 1. Name: 4/ 1e4 y � <br /> Address: / <br /> zip 7i <br /> Phone No.: ( <br /> Waste Type <br /> Quantity: g ,, <br /> ;>J gal. <br /> 4 <br /> Signature: `ter <br /> Date 22 d �?� .1! P.H. <br /> Within Stockton city limits? Yes (No] <br /> e <br /> 1 t <br /> Allowable Waste Type; Place applicable number in space provided above. <br /> 1. Residential Septage' 2. Portable Toilet" 3. Restaurant Grease Interrceptor 4. -Special <br /> Disharge" <br /> 'squw=WM mac be ivgaund,but k abi n sad ie w=m1 fe person shia be mdua o& <br /> A 4ccW Pe-ut must be completed and app M by sBW(]F before&Wk=g0 s stowed <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 /> above information or failure to comply with my Waste Hauler Permit and/or any applicable <br /> � <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 />