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STaCl TON R��tE�GIONAL �Vyy'.RRA�S�Tc CONTROLEWATECONTROLF`ACIUTY , <br /> STE <br /> MANUEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5060 <br /> MXAM PRM HARD (GObal.rl'E OR FORAM WH.L NOT BE ACCEMW <br /> Waste Hauler Co _ <br /> mpany Name Vehicle Capacity 3 <br /> Vehicle License No. Date 4- Zff—9 Load #_E _ <br /> Complete naso, 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 sore 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.: ( ) "�_tj `(�ZZ <br /> Waste Type: Quantity: 2.M3 gal. <br /> Signature: t <br /> Date: =2ZM Time: ' A.M. P.M. <br /> Within Stockton city limits? Yes No <br /> d ; <br /> Allowable Waste Type: Place applicable number in space provided above. <br /> 1. Residential Septage Portable Toilet* 3. Restaurant Grease Interceptor 4. Special <br /> Disharge" <br /> Sqp MK=WM sot ba ngw,e k but$=mu s wd iapaauit' pesos d aU be�d�cated = <br /> A Spakl Pa m►t most be eamplmd mad appmmd by SRWCF�aro die=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 /> WRWCF regulation, may result in the immediate suspension o Waste Hauler Permit and/or <br /> ther penalties as may be allowed by law. <br /> Waste Hauler Signature <br />