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.............. <br /> .................... <br /> MWW: <br /> .. .........STOKT£} <br /> ........ ... <br /> . ................ ................. <br /> .......... <br /> ................... ........ <br /> .. ........... ... .. ....... <br /> -S <br /> w E <br /> .'A H . <br /> ....... . <br /> - --------- <br /> TO BE COMPLETED BY WASTE HAiER BEFORE ENTRY TO SRWCF. 5068 <br /> PLEAMPRW Ok N.LEORaS FORM WML Nar IM ACC37= <br /> I <br /> Waste Hauler Company Name <br /> a—Vehicle Capacity <br /> t <br /> vehicle License j No. Date ef— ly—Key # 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," <br /> 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 y SRWCF. <br /> Name: <br /> Address: <br /> Zip, <br /> Phone No..: <br /> Waste Type:--',4- Quantity: gal. <br /> sigriature:— <br /> Date: A.M. P.M.. <br /> Within`Stockton city limits? Yes No . <br /> A <br /> G <br /> &boVe'L. <br /> Allowable=Waste <br /> Waste Types Place applicable number in� space provided <br /> - S - cial : <br /> �1.. Residential eptage. 2.: Portable' ,Toilet' �.3. . Restaurant Greasd'Interceptor., 4. Spe <br /> ftuawm wa X"'be rcquir4 but kcafim and zoVoseR&peraau shag be Wkaftd.' . <br /> —A, <br /> Rp=W Paraift m=be emplMd and Mpund by SRWCF bcfim&wJmgc is a9mcd. <br /> 1, the below named waste hauler, declare under .penalty of perjury, that .to the beat of my <br /> knowledge I haveaccurately described the type, ,quantity, and source of all wastes "which 'I-. <br /> now request to dispose of at' .the SRWCF. - I furtherde6lare,-.under:penalty of.perjury, .:that <br /> 'ILwas personally informed by the owner, owner's agent, or occupants of the..property-where _L <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 <br /> f perjury, that j the truck(d) 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 awar'e' 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 ler Permit and/or any .applicable . :. <br /> SRWCF regulation, may result in the immediate Bus' mio of my Waste Hauler Permit and/or <br /> -other penalties as may be allowed by law., <br /> Waste Pe' <br /> f my <br /> Waste. Ha <br /> % uler Si t <br /> _7 <br /> j <br />