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STOCKmN REGIONAL"WASTEWATER coNTROL-F'ACIx'Y v <br /> WAS'T'E HAIR MANWEST FORM-, v <br /> TO BE COMPLETED BY WASTE HAULER BEFORE ENTRY TO SRWCF. 5065 <br /> PLEME MWr HARDa 7j1,1.0 . <br /> FORMSWELL NOT BE ACCEPTEDry��Waste Hauler Company Namehicle Capacity, �� 7 � <br /> Vehicle License No. Date Key # a" 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: art 1 l a �Js <br /> Address: Vr S <br /> Zip i <br /> Phone No. : > 2 3 56 7 <br /> 4 <br /> Waste Type: Quantity: 2 3 gal. <br /> Signature: <br /> Date: 14 ,22 ime: • A.M. P.M. <br /> Within Stockton city limits? Yes No <br /> r <br /> f <br /> J � <br /> i <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 /> Disharge" w <br /> 'spa WM not be regmcd,but Imes m od,eapma1&peen.han be xmi=04 <br /> A special Perot=wt be kwd and appmvcd by SRWCF bd=&wbwp a spored <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 Iffailuto accurately describe the <br /> above information or failure to comply with my Waste ermit and/or any applicable <br /> SRWCF regulation, may result in the immediate suspensy Waste Hauler Permit and/or <br /> other penalties as may be allowed by law.Waste Hauler Signatu <br />