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STOC T01 1 GO�fA WA 1T A ER CONMOL F'ACILT Y <br /> . <br /> AS" EU 1VS' ' FOS <br /> :..:.. .... ..... <br /> TO BE COMPLET BY WASTE iER BEFORE ENTRY TO SRWCF. 5067 <br /> ! PLEASE PRM o U�p 3MLE FORMS wQ L NOT BE ACCEnTD. _ <br /> E ! <br /> waste Hauler Company Name I� Vehicle Capacitye <br /> r <br /> Vehicle License No. Date Key # Load # i <br /> Complete name, address, type, and quantity of waste source(s) below. A signature shall be <br /> f obtained froma representative from each source; verifying the type and quantity stated. <br /> If more than four sources is the waste load; attach additional forms. Random verification. <br /> will be-made by SRWCF. j <br /> � I I <br /> i <br /> 1. Name: <br /> Address: Ado L <br /> zip <br /> Phone No. : ( <br /> I Waste Type: ': h Quantity: gal. <br /> Signature: .—i <br /> Date: r- Time: A.M. P.M. <br /> Within Stockton city limits? Yes No <br /> �.. <br /> i e i <br /> - Allowable..Waste "Type: .Place .applicible number is space provided above. <br /> 1. Residential Septage' . 2. Portable Toilet' : 3. !!Restaurant Grease Interceptor 4. Special <br /> Disharge - i <br /> :9 <br /> Si;osbpra wall ant bo.Yvyuaed,6�a 1aea6oa and Gln peiaou■b■11 be iodicatod I ! <br /> A Special rams most W campided md.appm d by SRWCF bdf m&xhup is allmvd. <br /> I, the below named waste- hauler, declare under penalty of perjury, that .to the beet of my <br /> lknowledge .I have accurately described the type, �quantity, and source of all wastes which I - 1 now request ,to dispose-`of at the SRWCF. I further declare, under penalty .of perjury, that <br /> I -I•was personally informed by the owner,, owner'aOagent,-'or occupants of ths' property where <br /> jthis waste was received or have personal knowledge, .that .this waste contains -only <br /> i 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 /> f transport this waste was free of all materials-characterized by law as a hazardous waste . i <br /> f or substance at the time of said use. .I alp aware of the conditions and requirements of <br /> € the Waste Hauler Permit. Further, .1 understand ;that failure .to accurately describe the <br /> above information or failure to comply with my.Waste Hauler Permit and/or any applicable <br /> SRWCF regulation, may result in the immediate suFspensian Waste Hauler .Permit and/or .. <br /> j other penalties as may be allowed by law. <br /> 4 <br /> �. .Waste Hauler Signatur <br /> i <br /> A,. <br /> i <br />