Laserfiche WebLink
STOCKTON REGIONAL:WASTEWATER CONTROL FACILITY <br /> WASTE HAULER MANIFEST FORNix v <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5062 <br /> P XAW rs:[Irr AAWPCOM -M1 o Forces WMM NM aE ACCEPT» <br /> Waste Hauler Company Name Vehicle Capacity <br /> Vehicle License No. Date Key # Load #� <br /> Complete name, address,- tyre, and quanta y of waste source(=) 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 7n:aLQ-A <br /> 1. Name: <br /> Address: 1-7 ,01 S , [1�� �4 <br /> ^e � <br /> Zip <br /> Phone No. . ( ) <br /> Waste Type: Quantity:_gal. <br /> Signature: :� —a�g-,---_ <br /> •* a <br /> Date: r Time: A.M. P.M. <br /> Within Stockton city 1=its? Yes No <br /> rr <br /> M. FERMI <br /> d f <br /> s � • <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 /> 'Ruda er wM noc be rapnd,but beab=rid eaqm=1la puna AmR be ndeaoed <br /> A 8p=al Parma marc be camplesW rod apprwea by SRWCF bdfae die=AmW <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 /> OSRWCF regulation, may result in the immediate suspension o Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signatur <br />