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i <br /> K v V STOCKT'ON REGIONAL WASTEVATER CONTROL FACILITY <br /> WASM HA[ LFR NIANEMEST FORM <br /> TO BE COMPLETED BY WASTE HA BEFORE ENTRY TO SRWCF. <br /> PLEAM PRM ro� 5064 <br /> Waste Hauler Company Name 'OXW�NOT BE ACCRA <br /> Vehicle Vehicle Capacity <br /> License No. Date <br /> Complete name, address type, 4 — Rey # Loadf <br /> Obtained from a representativefrosouiag{xebelow. <br /> type and <br /> If sore than four sources is the xaste load; attach additional forms. Randomtr verification <br /> Will be quantity stated. <br /> Bade by l�RWCF. _ 7 <br /> 1. Name: <br /> Addresa:�"o''r.o <br /> Phone No.: { zip <br /> ) 07 <br /> Waste Type: Quantity <br /> Signature: gal. <br /> al. <br /> Date: Time: <br /> A.M. P.M. <br /> Within Stockton city limits? Yes No <br /> Allowable Waste Types Place applicable numbs <br /> I. Residential Septage' 2. port �3 "� space provided above. <br /> Disbar "' able Toilet 3. Restaurant ant Grease Interceptor 4. Special <br /> SWN*U s WM me be VXPweC Gert kmlb u and impauR&P<�"be zmhc; ed �, - J <br /> A Sperm pm"mot be eampleoed and apPXWW by SRWCF befera s a8oeved. <br /> I, the below named waste hauler, declare under penalty of perjury', <br /> knowledge I have accurately described the t that to the best of my <br /> now request to dispose of at the SRWCF. _ I type, quantity, <br /> andunderource of all wastes which I <br /> I was personally informed by the owner, owners agent, or occupantseoflthe o£ perjury. that <br /> this waste was received or have personal knowledge, that this waste containsronlyy where <br /> residential septa4e or grease, or in the case of a Special Permit, is-not ]iazardous 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 P rmit and/or any applicable <br /> SRWCF regulation, may result in the immediate suspension a <br /> Cher penalties as may be allowed by law. Waste Hauler Permit and/or <br /> haste Hauler Signature <br /> t. <br />