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V STO(�KTON <br /> ry r REGIONAL WASTEWATER CONTROL FAMITY <br /> WASTE HAULER MANNESiFORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5059 <br /> PX •.M P1 RTrPINCOMPL=O PORM3 WML I'M BE ACED <br /> Waste Hauler Company Name J9rT�.. o�lA.Ln o�.._��Vehicle Capacity <br /> G <br /> Vehicle License No. Date Rey # .2 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. Name: <br /> Address: ; <br /> zip <br /> Phone No. : ( ) <br /> Waste Type: `r Quantity: gal. <br /> Signature: <br /> Date: Z Time: -9 A.M. P.H. <br /> Within Stockton city limits? Yes No <br /> 1 r <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 /> Sqmmux=WM not be n+quned,but$=on as and nqKmxR&palm dug be ndm atod <br /> A Sparal Pamd mmt be a®platod and approved by SRWCF bdbm duehuv n a1{vwed <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 per3ury, 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 /> SRWCF regulation, may result in the immediate suspension o m Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signature <br />