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r <br /> STOOKTON REGIONAL WASTEWATER CONTROL FACIUTY -"L. <br /> WASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5025 <br /> PiE1.4E PRINT AND HARD IIQt�OMPL}*PS 4Rrrnsrp F000Wli .NOrI BE ACCEPTED <br /> Waste Hauler Company Name �r p Vehicle Capacity IBJ <br /> Vehicle License No. Date ey # 7 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 waste load; attach additional forms. Random verification <br /> will be made by SRWCF. <br /> 1. Namesz2 e4neYJ-4*1, <br /> Address: <br /> Phone No. : ( <br /> Waste Type:%, Quantity: r?c.,gal. <br /> Signature: ` <br /> y <br /> Date: Time: P.M. <br /> Within Stockton city limits? Yes <br /> • <br /> f <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage' 2. Portable Toilet' 3. Restaurant Grease Interceptor 4. Special <br /> Disharge <br /> 'sgnmum vel am be ngmwd,but laeabm and napomWNs pasm"be aodeawd <br /> A 9pxnl Pam6 nwa be eamplebod and approved by SRWCP Won daeba p 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 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 /> ORWCF regulation, may result in the immediate suspension of my Waste Hauler Permit and/or <br /> ther penalties as may be allowed by law. <br /> Waste Hauler Signature <br /> f <br />