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r: 1 <br /> j . <br /> ST�C�TOI�1�EGIO�A�'W'ASTE'V�AT �0�C1L�`ACILITY <br /> � x <br /> - ASTM`HACII.E� 'I' �O�M, <br /> ! TO BE COMPLETEDBY WASTE HAULER BEFORE ENTRY TO SRWCF. 5069 <br /> PLEASE PRII'Zr 3�RPIL+i o II�IEaIDIB FORMS VML NOT BE ACCEr=. <br /> Waste Hauler Company Name <br /> ehicle Capacity 7 l _ <br /> Vehicle License No. Date M Rey 1 Load # <br /> Complete name, address, type, and quantity of waste source(s) .below. A signature shall be <br /> l � obtained -from a representative .fron 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. - M <br /> 1. Name: /&Q�%L <br /> Address: <br /> I zip <br /> € Phone No. : ( <br /> Waste Type: 4 ' Quantity: a] <br /> i Signature: ; c ` <br /> Date: 0- Time: A.M. P-M <br /> I- <br /> Within. Stockton cit l is? - Yee No..-.:y <br /> - 1 <br /> Allowable- Waste Types.. Place applicable number," space pyrovided :above _ <br /> r;l : Residential:Septage' - 2.r. Portable'Toilet' :3.ARestaurant Grease..;Interceptor 4. ,Special <br /> Dishaige <br /> Signatmw wM sine be iegsiir4 bsit loea4m asid impd=R&pas=shmH be <br /> "A Special Pima mme be cdmpkftd rod Wmvcd bs SRWCP before fc is aBmcd.'.' <br /> X, the_'below named waste hauler,. declare under penalty of perjury,' that to the beat -of .my <br /> I Amowledge I, have accurately described.the. type,- quantity,: and` source.of all. wastes.which .I <br /> thiswastepna Y y r aste penalty of perjury; that <br /> now request to ,dispose of -at the,>SRWCF..`.I -further declare, ;under pe <br /> I was ; rsanall informed.b -the.;owner owner.-s�age'nty` or occupants.-of:the :property where - <br /> hi, s received or have personal knowledge, -that;this . 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 Control <br /> requirements. I also declare, runder penalty .ofperjury,-:that-,,the truck(s) used to <br /> transport thia- wast a was free -of all material s' characterized by law=as a hazardous waste <br /> or-substance at the time of said use: I am aware of the con ti;is and requirements of <br /> the Waste Hauler"Permit. Further, I underetandlthat fai re t : curately describe the <br /> above information or failure -to--.comply..with--my Waste H ler.P and/or any applicable <br /> SRWCF regulation, may result in the immedikte .suspens on of . Waste Hauler Permit and/or <br /> ether penaltiesas may.-be allowed by -law.' <br /> Waste Hauler :Signatu <br />