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STOCKTON REGIONAL WASTEWATER CONTROL FACILITY <br /> v - ''BASTE HAULER MANIFEST FORM <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5063 <br /> PLP <br /> A.SE PRIIYT awxn O PORM9 wa L NOT BE ACCEPTED <br /> Waste Hauler Company Name 9 Vehicle Capacity -003 <br /> Vehicle License No. Date Key # -2f„ Load # it __1q74n <br /> Complete name, address, type, and quantity of waste sources) below. A sign atur 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; ttach additional forms. Random verification <br /> will be made by SRW F r <br /> 1. Name: <br /> Address: <br /> zip d <br /> Phone No. : ( ) 753 35-407. <br /> Waste Type: ,i, antity: 3 gal. <br /> Signature: <br /> Date: Time: f A.M. P.M. <br /> Within Stockton city llmlts? Yes No <br /> r - <br /> IN Ila <br /> i <br /> J <br /> S <br /> Allowable Waste Types Place applicable number in space provided above. <br /> 1. Residential Septage 2. Portable Toilet` 3. Restaurant Grease Interceptor 4. Special <br /> DLsharge" <br /> SWeaan=WM nat be ee ...k but k caoat and mai '" petam aball be�od�eaWd <br /> A SpecW Paint mint be eampbud mind approved by SRWCF bdaa Awhwrje a&Ummd <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 fail o accurately describe the <br /> above information or failure to comply with my Waste Hau er r <br /> P mit and/or any applicable <br /> GSRWCF regulation, may result in the immediate suspensio of y Waste Hauler Permit and/or <br /> other penalties as may be allowed by law. <br /> Waste Hauler Signatur <br />